Healthcare Provider Details

I. General information

NPI: 1720424930
Provider Name (Legal Business Name): LORI LYNN HENDERSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD STE A7
POWAY CA
92064-2425
US

IV. Provider business mailing address

4550 KEARNY VILLA RD STE 116
SAN DIEGO CA
92123-1583
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax: 858-467-7161
Mailing address:
  • Phone: 858-279-1223
  • Fax: 858-467-7161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC42269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: