Provider Demographics
NPI:1629382387
Name:HENDERSON, TRICIA MARIE (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:MS
Other - First Name:TRICIA
Other - Middle Name:MARIE
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA
Mailing Address - Street 1:4001 ROSEDALE PL
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-4897
Mailing Address - Country:US
Mailing Address - Phone:281-543-5695
Mailing Address - Fax:
Practice Address - Street 1:4001 ROSEDALE PL
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-4897
Practice Address - Country:US
Practice Address - Phone:281-543-5695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-10-6945103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst