Provider Demographics
NPI:1790557304
Name:HENDERSON, MALIA PEARL (AUD)
Entity Type:Individual
Prefix:
First Name:MALIA
Middle Name:PEARL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3922
Mailing Address - Country:US
Mailing Address - Phone:360-774-6138
Mailing Address - Fax:
Practice Address - Street 1:197 E CAROLINE ST STE 1100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3731
Practice Address - Country:US
Practice Address - Phone:909-558-2053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3883237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter