| Doctor Name: | MR. MICAH SHANE HENDRICKSON |
| NPI Number: | 1063887164 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MA |
| License Number: | MH13683 |
| Business Practice Address: | 2523 Us Highway 27 S Ste 130 Avon Park, FL - 338257744 |
| Business Phone Number: | 8634520710 |
| Business Fax Number: | 8634520142 |
| Mailing Address: | 2523 Us Highway 27 S, Ste 130 AVON PARK |
| State: | FL |
| Postal Code: | 338257744 |
| Phone Number: | 8634520710 |
| Fax Number: | 8634520142 |
| NPI Enumeration Date: | 12/01/2015 |
| NPI Last Update Date: | 12/01/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | MH13683 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |