Provider Demographics
NPI:1558857052
Name:BURNS-HENDERSON, NICOLE (ASSOCIATE MFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BURNS-HENDERSON
Suffix:
Gender:F
Credentials:ASSOCIATE MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 GLENWAY DR UNIT 104
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-2724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1704 W MANCHESTER AVE STE 202A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3057
Practice Address - Country:US
Practice Address - Phone:310-650-7940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-08
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74236101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health