Provider Demographics
NPI:1710558317
Name:HENDERSON, KYRA ELISE (MS)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:ELISE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 15TH AVE APT 21
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-2827
Mailing Address - Country:US
Mailing Address - Phone:714-296-6108
Mailing Address - Fax:
Practice Address - Street 1:1115 B ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4028
Practice Address - Country:US
Practice Address - Phone:707-765-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist