Provider Demographics
NPI:1760016125
Name:HENDERSON, NANCY J
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
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 1:3501 JUAN TABO BLVD NE UNIT A4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5112
Mailing Address - Country:US
Mailing Address - Phone:312-719-3885
Mailing Address - Fax:
Practice Address - Street 1:2741 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2653
Practice Address - Country:US
Practice Address - Phone:505-750-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0208331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty