Provider Demographics
NPI:1679331193
Name:THACH, ETIENNE MARSHALL (RBT)
Entity type:Individual
Prefix:
First Name:ETIENNE
Middle Name:MARSHALL
Last Name:THACH
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 12TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-6451
Mailing Address - Country:US
Mailing Address - Phone:714-801-4038
Mailing Address - Fax:
Practice Address - Street 1:840 12TH AVE APT A
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-6451
Practice Address - Country:US
Practice Address - Phone:714-801-4038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-332667106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician