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NPI Code Detail

MEDICARE: MS. CARLY MARIE HENDERSON M.A., LPC, LMHC

MEDICARE: MS. CARLY MARIE HENDERSON M.A., LPC, LMHC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional CounselorC3645OR

General Provider Information

NPI Number : 1194017764
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. CARLY MARIE HENDERSON M.A., LPC, LMHC
Provider Business Mailing Address
First Line : 1016 SE 12TH AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97214-2513
Country : US
Telephone Number : 971-270-0658
Fax Number : 971-244-7268
Provider Business Practice Location Address
First Line : 3407 S CORBETT AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97239-4621
Country : US
Telephone Number : 971-270-0658
Fax Number : 971-244-7268
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/13/2011
Last Update Date : 02/21/2024

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