Healthcare Provider Details

I. General information

NPI: 1760016125
Provider Name (Legal Business Name): NANCY J HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

IV. Provider business mailing address

3501 JUAN TABO BLVD NE UNIT A4
ALBUQUERQUE NM
87111-5112
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-8866
  • Fax:
Mailing address:
  • Phone: 312-719-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0208331
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: