Provider Demographics
NPI:1659326528
Name:HENDERSHOT, KIRSTEN PAULINE (LPC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:PAULINE
Last Name:HENDERSHOT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:P
Other - Last Name:HENDERSHOT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:2538 BIG HORN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9299
Mailing Address - Country:US
Mailing Address - Phone:307-587-3219
Mailing Address - Fax:307-527-6218
Practice Address - Street 1:2538 BIG HORN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9299
Practice Address - Country:US
Practice Address - Phone:307-587-3219
Practice Address - Fax:307-527-6218
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC1527101YA0400X
AZLPC10414101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ734766OtherAHCCCS