Provider Demographics
NPI:1629744305
Name:HENDERSON, BARBARA BETH
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:BETH
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 1:7125 E STARDUST LN
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86315-4732
Mailing Address - Country:US
Mailing Address - Phone:760-608-0157
Mailing Address - Fax:
Practice Address - Street 1:200 N AMERICAN ST
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3943
Practice Address - Country:US
Practice Address - Phone:760-608-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2795932471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography