Provider Demographics
NPI:1245713049
Name:HENDERSON, ANICA
Entity type:Individual
Prefix:MISS
First Name:ANICA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ANICA
Other - Middle Name:
Other - Last Name:STAMSTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5230 BRODIE GRV APT 307
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-6513
Mailing Address - Country:US
Mailing Address - Phone:262-308-8449
Mailing Address - Fax:
Practice Address - Street 1:2760 FIELDSTONE RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3100
Practice Address - Country:US
Practice Address - Phone:719-203-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18-64779106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician