=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720594120
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT HENDERSON LADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 N GREEN VALLEY PKWY
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89014-0273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-385-3330
-----------------------------------------------------
Fax | 702-924-2575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1711 WHITNEY MESA DR
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89014-2080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-385-2090
-----------------------------------------------------
Fax | 702-924-2575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LADC01683-L
-----------------------------------------------------
License Number State |
-----------------------------------------------------