Provider Demographics
NPI:1801326525
Name:HENDERSON, TRAVIS BRETT (EDD, BCBA)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:BRETT
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:EDD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3870 SAN JOSE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4613
Mailing Address - Country:US
Mailing Address - Phone:888-963-2228
Mailing Address - Fax:
Practice Address - Street 1:3870 SAN JOSE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4613
Practice Address - Country:US
Practice Address - Phone:888-963-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-10-6972103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021099300Medicaid