MEDICARE: ALYSIA DAWN HENDERSON MS

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1972010197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSIA DAWN HENDERSON MS

Provider Business Mailing Address
First Line	:	2024 CLARMAR WAY APT 8
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95128-1709
Country	:	US
Telephone Number	:	408-838-1834
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 W ORANGE AVE
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-4443
Country	:	US
Telephone Number	:	408-838-1834
Fax Number	:

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

Provider Enumeration Date	:	01/09/2018
Last Update Date	:	03/17/2018

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