Provider Demographics
NPI:1043547078
Name:HENDERLONG, DEBRA M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:M
Last Name:HENDERLONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MAIN ST
Mailing Address - Street 2:STE 301 ALLIES INC.
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6359
Mailing Address - Country:US
Mailing Address - Phone:207-941-8727
Mailing Address - Fax:207-992-2784
Practice Address - Street 1:21 MAIN ST
Practice Address - Street 2:STE 301 ALLIES INC.
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6359
Practice Address - Country:US
Practice Address - Phone:207-941-8727
Practice Address - Fax:207-992-2784
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC68901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434425599Medicaid