Provider Demographics
NPI:1013646397
Name:HENDERSON, MARY ELIZABETH (CSC-AD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 DRYER AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1018
Mailing Address - Country:US
Mailing Address - Phone:301-338-0999
Mailing Address - Fax:
Practice Address - Street 1:14701 NATIONAL HWY SW STE 5&6
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-6573
Practice Address - Country:US
Practice Address - Phone:301-687-0940
Practice Address - Fax:301-687-0948
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC3073101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)