Healthcare Provider Details

I. General information

NPI: 1508909771
Provider Name (Legal Business Name): REBECCA CARR HENDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 S 2ND AVE
COVINA CA
91723-3013
US

IV. Provider business mailing address

1777 LA CRESTA DR
PASADENA CA
91103-1262
US

V. Phone/Fax

Practice location:
  • Phone: 626-974-0770
  • Fax: 626-974-0774
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23361
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: