Provider Demographics
NPI:1548786148
Name:KLICH HENDERSON, LAURA SUSAN (BCBA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUSAN
Last Name:KLICH HENDERSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 18TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4216
Mailing Address - Country:US
Mailing Address - Phone:727-772-3053
Mailing Address - Fax:
Practice Address - Street 1:30250 SOUTHWELL LN
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5926
Practice Address - Country:US
Practice Address - Phone:727-772-3053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-54929103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst