Provider Demographics
NPI:1689178584
Name:HENDERSON, BLAKE (BCBA, M ED)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:BCBA, M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 E IMPERIAL HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-1706
Mailing Address - Country:US
Mailing Address - Phone:657-444-9002
Mailing Address - Fax:
Practice Address - Street 1:290 S PROSPECT AVE STE A
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1523
Practice Address - Country:US
Practice Address - Phone:415-646-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-29346103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst