Healthcare Provider Details

I. General information

NPI: 1740868793
Provider Name (Legal Business Name): NATHAN HENDRICKS MA, PLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 E VAUGHN AVE
RUSTON LA
71270-5928
US

IV. Provider business mailing address

330 E VAUGHN AVE
RUSTON LA
71270-5928
US

V. Phone/Fax

Practice location:
  • Phone: 318-224-7135
  • Fax:
Mailing address:
  • Phone: 318-224-7135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8513
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8513
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: