Provider Demographics
NPI:1225547508
Name:HENDERSON, MARY KATHLEEN (LADC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPSTEAD
Mailing Address - State:NH
Mailing Address - Zip Code:03826-0431
Mailing Address - Country:US
Mailing Address - Phone:503-560-2854
Mailing Address - Fax:
Practice Address - Street 1:393 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:NH
Practice Address - Zip Code:03819-3219
Practice Address - Country:US
Practice Address - Phone:603-560-2854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH0125101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)