Provider Demographics
NPI:1144007147
Name:DATU, JOSEPH MARTIN BACAY
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MARTIN BACAY
Last Name:DATU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7002 HAWAII KAI DR APT 1911
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-4209
Mailing Address - Country:US
Mailing Address - Phone:808-724-7531
Mailing Address - Fax:
Practice Address - Street 1:91-1159 KAMAKANA ST APT 120
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2023
Practice Address - Country:US
Practice Address - Phone:808-721-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBACB981803106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician