Provider Demographics
NPI:1225658180
Name:HENDERSON, HOLLY A (MA, LMHC)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 40TH ST N APT 208
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-6340
Mailing Address - Country:US
Mailing Address - Phone:617-459-7751
Mailing Address - Fax:
Practice Address - Street 1:600 40TH ST N APT 208
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6340
Practice Address - Country:US
Practice Address - Phone:617-459-7751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13444101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health