Provider Demographics
NPI:1689004780
Name:HENRY, JUSTINE (MS,BCBA)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:MS,BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-6982
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1026 PATHFINDER WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3216
Practice Address - Country:US
Practice Address - Phone:321-655-5880
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14889103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst