Provider Demographics
NPI:1366034878
Name:HENDERSON, TYLIE SHAE
Entity Type:Individual
Prefix:
First Name:TYLIE
Middle Name:SHAE
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 1:1484 N 950 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-1099
Mailing Address - Country:US
Mailing Address - Phone:801-822-6716
Mailing Address - Fax:
Practice Address - Street 1:56-660 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:KAHUKU
Practice Address - State:HI
Practice Address - Zip Code:96731-2210
Practice Address - Country:US
Practice Address - Phone:801-822-6716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)