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NPI Code Detail

MEDICARE: BLAKE HENDERSON BCBA, M. ED.

MEDICARE: BLAKE HENDERSON BCBA, M. ED.
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
1103K00000XBehavior Analyst1-18-29346CA

General Provider Information

NPI Number : 1689178584
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAKE HENDERSON BCBA, M. ED.
Provider Business Mailing Address
First Line : PO BOX 740780
Second Line :
City : ATLANTA
State : GA
Zip : 30374-0780
Country : US
Telephone Number : 855-223-7123
Fax Number :
Provider Business Practice Location Address
First Line : 12604 HIDDENCREEK WAY STE C
Second Line :
City : CERRITOS
State : CA
Zip : 90703-2137
Country : US
Telephone Number : 562-261-9101
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/23/2018
Last Update Date : 05/26/2026

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