Provider Demographics
NPI:1235106469
Name:HENDERSON, JOANN H (BSW, MA, LPC, QMRP)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:H
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:BSW, MA, LPC, QMRP
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 103
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815-0103
Mailing Address - Country:US
Mailing Address - Phone:540-476-1482
Mailing Address - Fax:540-896-3209
Practice Address - Street 1:409 BRETHREN RD
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:VA
Practice Address - Zip Code:22815-2847
Practice Address - Country:US
Practice Address - Phone:540-476-1482
Practice Address - Fax:540-896-3209
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004506101YP2500X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4946995Medicaid