Provider Demographics
NPI:1275833592
Name:HENDERSON, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:HENDERSON
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 1:9402 W LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-8312
Mailing Address - Country:US
Mailing Address - Phone:702-530-3124
Mailing Address - Fax:
Practice Address - Street 1:9402 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-8312
Practice Address - Country:US
Practice Address - Phone:702-530-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204989106H00000X
VA0717002070106H00000X
NV4284106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist