1285180026 NPI number — MRS. MICHELLE ODUM HENDERSON BCBA

Table of content: MRS. MICHELLE ODUM HENDERSON BCBA (NPI 1285180026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285180026 NPI number — MRS. MICHELLE ODUM HENDERSON BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
MICHELLE
Provider Middle Name:
ODUM
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285180026
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2740 COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72034-6141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-329-5459
Provider Business Mailing Address Fax Number:
501-327-1738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5566 MAIN ST STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRISCO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75033-3674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-687-9374
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-16-22870 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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