Healthcare Provider Details

I. General information

NPI: 1417851320
Provider Name (Legal Business Name): RE'AUNNA M HENDERSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 W MAGNOLIA BLVD
BURBANK CA
91505-3031
US

IV. Provider business mailing address

9246 LIGHTWAVE AVE STE 120
SAN DIEGO CA
92123-6411
US

V. Phone/Fax

Practice location:
  • Phone: 800-270-5016
  • Fax: 800-680-3626
Mailing address:
  • Phone: 800-270-5016
  • Fax: 800-680-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB94029516
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License NumberPSB94029516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: