Provider Demographics
NPI:1124594577
Name:HENDERSON, SHAROLYN
Entity Type:Individual
Prefix:
First Name:SHAROLYN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20055 SALLIE DR
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-5321
Mailing Address - Country:US
Mailing Address - Phone:225-892-4564
Mailing Address - Fax:
Practice Address - Street 1:20055 SALLIE DR
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-5321
Practice Address - Country:US
Practice Address - Phone:225-892-4564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA00000Medicaid