Provider Demographics
NPI:1174007157
Name:HENDERSON, KATHLEEN (LBSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 LA JARA ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6626
Mailing Address - Country:US
Mailing Address - Phone:505-634-3863
Mailing Address - Fax:
Practice Address - Street 1:310 LA JARA ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6626
Practice Address - Country:US
Practice Address - Phone:505-634-3863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-085131041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty