Healthcare Provider Details

I. General information

NPI: 1689178584
Provider Name (Legal Business Name): BLAKE HENDERSON BCBA, M. ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 05/08/2023
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 S PROSPECT AVE STE A
TUSTIN CA
92780-1523
US

IV. Provider business mailing address

3230 E IMPERIAL HWY STE 203
BREA CA
92821-1706
US

V. Phone/Fax

Practice location:
  • Phone: 415-646-6223
  • Fax:
Mailing address:
  • Phone: 657-444-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-29346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: