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General NPI Number Information
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NPI Number | 1548786148
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Entity Type | Individual
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Provider Name | LAURA SUSAN KLICH HENDERSON BCBA
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Gender | Female
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Dates
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Enumeration Date | 08/16/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 30250 SOUTHWELL LN
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City | WESLEY CHAPEL
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State | FL
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Zip | 33543-5926
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Country | US
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Telephone | 727-772-3053
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Fax |
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Provider Business Mailing Address
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Address Line | 5301 18TH AVE S
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City | GULFPORT
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State | FL
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Zip | 33707-4216
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Country | US
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Telephone | 727-772-3053
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-21-54929
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License Number State | FL
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