Provider Demographics
NPI:1134217656
Name:FACKLER, BETTY A (PT)
Entity type:Individual
Prefix:MS
First Name:BETTY
Middle Name:A
Last Name:FACKLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:BETTY
Other - Middle Name:ANN
Other - Last Name:FELLBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:82-6066 MAMALAHOA HWY
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CAPTAIN COOK
Mailing Address - State:HI
Mailing Address - Zip Code:96704-8204
Mailing Address - Country:US
Mailing Address - Phone:808-323-8123
Mailing Address - Fax:808-323-8125
Practice Address - Street 1:82-6066 MAMALAHOA HWY
Practice Address - Street 2:SUITE 7
Practice Address - City:CAPTAIN COOK
Practice Address - State:HI
Practice Address - Zip Code:96704-8204
Practice Address - Country:US
Practice Address - Phone:808-323-8123
Practice Address - Fax:808-323-8125
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH102115Medicare PIN