Healthcare Provider Details

I. General information

NPI: 1811668536
Provider Name (Legal Business Name): ALEXIS IRENE HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 GRANDE BLVD SE
RIO RANCHO NM
87124-1799
US

IV. Provider business mailing address

10228 NACIMIENTO ST NW
ALBUQUERQUE NM
87114-4456
US

V. Phone/Fax

Practice location:
  • Phone: 505-489-8034
  • Fax:
Mailing address:
  • Phone: 505-263-9525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: