Provider Demographics
NPI:1093214181
Name:HENDERSON, LATASHA SPENCER (LICSW)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:SPENCER
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 SERENE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:MC CALLA
Mailing Address - State:AL
Mailing Address - Zip Code:35111-3204
Mailing Address - Country:US
Mailing Address - Phone:205-540-4463
Mailing Address - Fax:
Practice Address - Street 1:5700 SERENE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:MC CALLA
Practice Address - State:AL
Practice Address - Zip Code:35111-3204
Practice Address - Country:US
Practice Address - Phone:205-540-4463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4107C101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL$$$$$$$$$OtherN/A