Basic Information
| Provider Information | |||||||||
| NPI: | 1285180026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ODUM | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2740 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720346141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013295459 | ||||||||
| FaxNumber: | 5013271738 | ||||||||
| Practice Location | |||||||||
| Address1: | 5566 MAIN ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750333674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146879374 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-16-22870 | CO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.