Provider Demographics
NPI:1225020696
Name:HENDERSON, DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:FRANCES
Other - Middle Name:DIANE
Other - Last Name:HOLDSWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1634 MARVELLE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-2326
Mailing Address - Country:US
Mailing Address - Phone:252-903-9926
Mailing Address - Fax:252-231-1062
Practice Address - Street 1:311 JUDGES RD
Practice Address - Street 2:4E
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3651
Practice Address - Country:US
Practice Address - Phone:910-791-6767
Practice Address - Fax:910-791-6890
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0017331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC40981OtherBCBS NC
62-00248OtherEVERCARE
NC6003386Medicaid
P00158971Medicare PIN
NC6003386Medicaid