Basic Information
| Provider Information | |||||||||
| NPI: | 1801336896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKSON | ||||||||
| FirstName: | VERDELL | ||||||||
| MiddleName: | MELODY | ||||||||
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| Credential: | CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | SAINT STEPHENS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825240190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078560470 | ||||||||
| FaxNumber: | 3078574383 | ||||||||
| Practice Location | |||||||||
| Address1: | 15455 65TH AVE S | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981882534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067215170 | ||||||||
| FaxNumber: | 2067216288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 60749932 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 156 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.