Provider Demographics
NPI:1720594120
Name:HENDERSON, ROBERT (LADC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1711 WHITNEY MESA DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2080
Mailing Address - Country:US
Mailing Address - Phone:702-385-2090
Mailing Address - Fax:702-924-2575
Practice Address - Street 1:2501 N GREEN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-0273
Practice Address - Country:US
Practice Address - Phone:702-385-3330
Practice Address - Fax:702-924-2575
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADC01683-L101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)