Provider Demographics
NPI:1366269458
Name:PADEKEN, TYRAH
Entity type:Individual
Prefix:
First Name:TYRAH
Middle Name:
Last Name:PADEKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56-170 PUALALEA ST
Mailing Address - Street 2:
Mailing Address - City:KAHUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96731-2017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56-170 PUALALEA ST
Practice Address - Street 2:
Practice Address - City:KAHUKU
Practice Address - State:HI
Practice Address - Zip Code:96731-2017
Practice Address - Country:US
Practice Address - Phone:808-305-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician