Basic Information
| Provider Information | |||||||||
| NPI: | 1770940181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRY | ||||||||
| FirstName: | KRIS | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENRY | ||||||||
| OtherFirstName: | KRISTOFER | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 842 CABALLO AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095443464 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14240 IMPERIAL HWY | ||||||||
| Address2: | |||||||||
| City: | LA MIRADA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906381940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629461587 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2016 | ||||||||
| LastUpdateDate: | 04/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.