Provider Demographics
NPI:1194017764
Name:HENDERSON, CARLY MARIE (MA, LPC, LMHC)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MA, LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 SE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2513
Mailing Address - Country:US
Mailing Address - Phone:971-270-0658
Mailing Address - Fax:971-244-7268
Practice Address - Street 1:3407 S CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4621
Practice Address - Country:US
Practice Address - Phone:971-270-0658
Practice Address - Fax:971-244-7268
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3645101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional