MEDICARE: MRS. MEGAN RENEE HENDRICKSON BCBA, LBA

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	124910	AK

General Provider Information

NPI Number	:	1417476540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MEGAN RENEE HENDRICKSON BCBA, LBA

Provider Business Mailing Address
First Line	:	8937 HAFFNER CT
Second Line	:
City	:	JUNEAU
State	:	AK
Zip	:	99801-8890
Country	:	US
Telephone Number	:	360-630-9163
Fax Number	:

Provider Business Practice Location Address
First Line	:	16941 N EAGLE RIVER LOOP RD
Second Line	:
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7824
Country	:	US
Telephone Number	:	907-726-5330
Fax Number	:

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

Provider Enumeration Date	:	09/09/2017
Last Update Date	:	07/21/2022

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