1043573116 NPI number — MS. CHERYL ANITA HENDERSON M.A., CCC-A

Table of content: MS. CHERYL ANITA HENDERSON M.A., CCC-A (NPI 1043573116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043573116 NPI number — MS. CHERYL ANITA HENDERSON M.A., CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
CHERYL
Provider Middle Name:
ANITA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENDERSON
Provider Other First Name:
CHERYL
Provider Other Middle Name:
ANITA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A. CCC-A
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043573116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 KENMOOR AVE SE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546-8622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-575-1208
Provider Business Mailing Address Fax Number:
616-575-1219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 KENMOOR AVE SE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-8622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-575-1208
Provider Business Practice Location Address Fax Number:
616-575-1219
Provider Enumeration Date:
06/22/2012

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: 237600000X , with the licence number:  1601000158 , 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)





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