Healthcare Provider Details

I. General information

NPI: 1588933949
Provider Name (Legal Business Name): TRACI MARIE HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W WARM SPRINGS RD STE 129
HENDERSON NV
89014-7636
US

IV. Provider business mailing address

1481 W WARM SPRINGS RD STE 129
HENDERSON NV
89014-7636
US

V. Phone/Fax

Practice location:
  • Phone: 702-547-0201
  • Fax: 702-944-7846
Mailing address:
  • Phone: 702-547-0201
  • Fax: 702-944-7846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: