Healthcare Provider Details

I. General information

NPI: 1912386905
Provider Name (Legal Business Name): SHIRLEY KATHRYN HENDERSON LICENSED COUNSELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 E GORDON DR COVENANT COUNSELING
KINGMAN AZ
86409-2736
US

IV. Provider business mailing address

4366 BOX J DR
KINGMAN AZ
86401-7348
US

V. Phone/Fax

Practice location:
  • Phone: 928-530-6778
  • Fax:
Mailing address:
  • Phone: 928-530-6778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: