Provider Demographics
NPI:1366830796
Name:HENDERSON, ALICIA A (PHD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-221-0223
Mailing Address - Fax:801-221-0291
Practice Address - Street 1:1355 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-221-0223
Practice Address - Fax:801-221-0291
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8905254-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist