Provider Demographics
NPI:1871250050
Name:HENDRICKS, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MISSION AUTISM CLINICS
Mailing Address - Street 2:351 TENNY STREET
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815
Mailing Address - Country:US
Mailing Address - Phone:888-726-4774
Mailing Address - Fax:570-362-5112
Practice Address - Street 1:360 MILLER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1830
Practice Address - Country:US
Practice Address - Phone:570-204-7518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician