Healthcare Provider Details

I. General information

NPI: 1912721424
Provider Name (Legal Business Name): RAYMOND HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 CALIFORNIA ST FL 12
SAN FRANCISCO CA
94104-1033
US

IV. Provider business mailing address

447 SUTTER ST STE 405
SAN FRANCISCO CA
94108-4618
US

V. Phone/Fax

Practice location:
  • Phone: 415-992-6155
  • Fax:
Mailing address:
  • Phone: 415-992-6155
  • Fax: 650-360-6913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number15461
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number143663
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: