Healthcare Provider Details

I. General information

NPI: 1699601443
Provider Name (Legal Business Name): STEPHANIE NICHOLE HENDERSON RT1444430526
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12120 HERDAL DR
AUBURN CA
95603-5637
US

IV. Provider business mailing address

12120 HERDAL DR
AUBURN CA
95603-5637
US

V. Phone/Fax

Practice location:
  • Phone: 408-450-5030
  • Fax:
Mailing address:
  • Phone: 408-450-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1444430526
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: