1235289810 NPI number — LAURA S HENDERSON MSW CSW

Table of content: NINA VANDAM (NPI 1215793989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235289810 NPI number — LAURA S HENDERSON MSW CSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
LAURA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW CSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235289810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 S HIGHLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT CLEMENS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48043-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-219-0504
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43200 DEQUINDRE RD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
STERLING HTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48314-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-799-4350
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801068425 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)