Healthcare Provider Details

I. General information

NPI: 1477311066
Provider Name (Legal Business Name): REBECCA MARIE HENDERSON LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12351 E BRADSHAW MOUNTAIN RD UNIT 176
DEWEY AZ
86327-6070
US

IV. Provider business mailing address

12351 E BRADSHAW MOUNTAIN RD UNIT 176
DEWEY AZ
86327-6070
US

V. Phone/Fax

Practice location:
  • Phone: 714-274-3590
  • Fax:
Mailing address:
  • Phone: 714-274-2590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-22641
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLAC-22641
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: