Healthcare Provider Details

I. General information

NPI: 1902165830
Provider Name (Legal Business Name): JOSEPH HENDERSON MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2012
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26520 CACTUS AVE
MORENO VALLEY CA
92555-3927
US

IV. Provider business mailing address

39545 DIEGO DR
TEMECULA CA
92591-7256
US

V. Phone/Fax

Practice location:
  • Phone: 951-486-5663
  • Fax:
Mailing address:
  • Phone: 951-529-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number70980
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: