Provider Demographics
NPI:1902376353
Name:HENNISON, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:HENNISON
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 1:14782 SEQUOIA ST APT 7
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1676
Mailing Address - Country:US
Mailing Address - Phone:909-487-4870
Mailing Address - Fax:
Practice Address - Street 1:14782 SEQUOIA ST APT 7
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1676
Practice Address - Country:US
Practice Address - Phone:909-487-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician