Provider Demographics
NPI:1093239618
Name:HENRY, BEONICA (RBT)
Entity Type:Individual
Prefix:
First Name:BEONICA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 N PENNSYLVANIA AVE APT 1421
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-5910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 POINTE PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-0600
Practice Address - Country:US
Practice Address - Phone:405-805-6403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator