Provider Demographics
NPI:1033468681
Name:HENDERSON, SHELLEY (LCSW R)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 W END AVE APT 1203
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5316
Mailing Address - Country:US
Mailing Address - Phone:646-600-1784
Mailing Address - Fax:
Practice Address - Street 1:808 W END AVE APT 1203
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5316
Practice Address - Country:US
Practice Address - Phone:646-600-1784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR018057-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300107665Medicare PIN