Provider Demographics
NPI:1043978869
Name:HENRICKSON, NATHALIA
Entity Type:Individual
Prefix:
First Name:NATHALIA
Middle Name:
Last Name:HENRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 79TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5931
Mailing Address - Country:US
Mailing Address - Phone:224-542-8572
Mailing Address - Fax:
Practice Address - Street 1:415 WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5564
Practice Address - Country:US
Practice Address - Phone:224-480-4642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional