Provider Demographics
NPI:1932646247
Name:HENDERSON, MINELL
Entity Type:Individual
Prefix:
First Name:MINELL
Middle Name:
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:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC
Mailing Address - Street 2:PO BOX 86537
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:480-845-9222
Mailing Address - Fax:
Practice Address - Street 1:1320 E PALO VERDE DR.
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122
Practice Address - Country:US
Practice Address - Phone:480-845-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5085385H00000X
AZ9233373171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5085OtherAZ DEPT OF HEALTH SERVICES
AZBH5085OtherAZ DEPT OF HEALTH SERVICES