MEDICARE: REGINALD HENDERSON SR.

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	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1811429335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINALD HENDERSON SR.

Provider Business Mailing Address
First Line	:	2525 SW KENILWORTH ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-2575
Country	:	US
Telephone Number	:	772-207-6323
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 SW KENILWORTH ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-2575
Country	:	US
Telephone Number	:	772-207-6323
Fax Number	:

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

Provider Enumeration Date	:	04/03/2017
Last Update Date	:	04/03/2017

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