Provider Demographics
NPI:1023034758
Name:HENDERSON, ELIZABETH CONNELL (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:CONNELL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:3848 COUNTY ROAD 24
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:MS
Practice Address - Zip Code:39332-2630
Practice Address - Country:US
Practice Address - Phone:601-260-5939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS109442084A0401X, 2084P0800X
NY2918712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B30069Medicare UPIN