Provider Demographics
NPI:1659814218
Name:HENRY, KRISTINE (BCBA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:CONGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:10604 N TRADEMARK PKWY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5938
Mailing Address - Country:US
Mailing Address - Phone:714-697-5480
Mailing Address - Fax:
Practice Address - Street 1:10604 N TRADEMARK PKWY
Practice Address - Street 2:SUITE 310
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5938
Practice Address - Country:US
Practice Address - Phone:714-697-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-15833103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst