Provider Demographics
NPI:1619085222
Name:HENDERSON, KIMBERLY J (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 MIRADA DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4099
Mailing Address - Country:US
Mailing Address - Phone:360-704-8298
Mailing Address - Fax:360-866-0770
Practice Address - Street 1:222 KENYON ST NW
Practice Address - Street 2:SUITE 10
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4553
Practice Address - Country:US
Practice Address - Phone:360-704-8298
Practice Address - Fax:360-866-0770
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00009495101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1981125Medicaid