1821076985 NPI number — CAROLYN R. HENDERSON MFT

Table of content: CAROLYN R. HENDERSON MFT (NPI 1821076985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821076985 NPI number — CAROLYN R. HENDERSON MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
CAROLYN
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MFT
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:
1821076985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N LAS FLORES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NIPOMO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93444-9246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-704-4640
Provider Business Mailing Address Fax Number:
805-929-2717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
641 HIGUERA ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-3549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-596-0234
Provider Business Practice Location Address Fax Number:
805-929-2717
Provider Enumeration Date:
01/08/2006

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: 106H00000X , with the licence number:  MFC37330 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MFC37330 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com