Provider Demographics
NPI:1073154118
Name:HEASELGRAVE, NATASHA FAYE (MSC, BCBA)
Entity Type:Individual
Prefix:MISS
First Name:NATASHA
Middle Name:FAYE
Last Name:HEASELGRAVE
Suffix:
Gender:F
Credentials:MSC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 SW 103RD AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1881
Mailing Address - Country:US
Mailing Address - Phone:954-330-7611
Mailing Address - Fax:
Practice Address - Street 1:403 SW 103RD AVE APT 304
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1881
Practice Address - Country:US
Practice Address - Phone:954-330-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-25532103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst