Provider Demographics
NPI:1831939396
Name:HENDRICKSON, KATELYN R (MED, BCBA)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:R
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BALD HILL TER
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-4024
Mailing Address - Country:US
Mailing Address - Phone:570-832-3212
Mailing Address - Fax:
Practice Address - Street 1:270 SPARTA AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1122
Practice Address - Country:US
Practice Address - Phone:570-351-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12369696103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst