MEDICARE: BRIANA HENDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1053842369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIANA HENDERSON

Provider Business Mailing Address
First Line	:	3365 W CRAIG RD
Second Line	:	SUITE#25
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-5112
Country	:	US
Telephone Number	:	702-955-0628
Fax Number	:	702-247-4535

Provider Business Practice Location Address
First Line	:	3365 W CRAIG RD
Second Line	:	SUITE 25
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-5112
Country	:	US
Telephone Number	:	702-955-0628
Fax Number	:	702-247-4535

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2017
Last Update Date	:	03/27/2017

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