Basic Information
| Provider Information | |||||||||
| NPI: | 1720594120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1711 WHITNEY MESA DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890142080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023852090 | ||||||||
| FaxNumber: | 7029242575 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 N GREEN VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890140273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023853330 | ||||||||
| FaxNumber: | 7029242575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LADC01683-L | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.