Provider Demographics
NPI:1821076985
Name:HENDERSON, CAROLYN R (MFT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N LAS FLORES DR
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9246
Mailing Address - Country:US
Mailing Address - Phone:805-704-4640
Mailing Address - Fax:805-929-2717
Practice Address - Street 1:641 HIGUERA ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3549
Practice Address - Country:US
Practice Address - Phone:805-596-0234
Practice Address - Fax:805-929-2717
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-08
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37330106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC37330OtherLICENSE