Healthcare Provider Details

I. General information

NPI: 1245164532
Provider Name (Legal Business Name): REBECCA HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 DAVIS LAKE RD
LAPEER MI
48446-1485
US

IV. Provider business mailing address

237 DAVIS LAKE RD
LAPEER MI
48446-1485
US

V. Phone/Fax

Practice location:
  • Phone: 810-667-9132
  • Fax: 810-667-0026
Mailing address:
  • Phone: 810-667-9132
  • Fax: 810-667-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704308459
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: