MEDICARE: MR. DARRYL HENDERSON L.C.S.W.

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
1	1041C0700X	Clinical Social Worker	4556-C	NV

General Provider Information

NPI Number	:	1497938211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARRYL HENDERSON L.C.S.W.

Provider Business Mailing Address
First Line	:	5728 EMERALD VIEW ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-1562
Country	:	US
Telephone Number	:	702-823-3085
Fax Number	:	702-823-3017

Provider Business Practice Location Address
First Line	:	5710 SIMMONS ST STE 102
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-7281
Country	:	US
Telephone Number	:	702-823-3085
Fax Number	:	702-823-3017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2007
Last Update Date	:	09/29/2009

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