Basic Information
| Provider Information | |||||||||
| NPI: | 1962076422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INNERST | ||||||||
| FirstName: | MYKAYLA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | BEHAVIOR TECHNICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91-1001 KEAUNUI DR UNIT 362 | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967066345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024034317 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1330 ALA MOANA BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968144262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085851424 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2021 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.