Provider Demographics
NPI:1235236035
Name:HENDERSON, ELIZABETH ANN (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:SURGENT (BOHN)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11400 LLOYD ST NW
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-8614
Mailing Address - Country:US
Mailing Address - Phone:330-313-4418
Mailing Address - Fax:
Practice Address - Street 1:4150 BELDEN VILLAGE ST NW
Practice Address - Street 2:#110
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2595
Practice Address - Country:US
Practice Address - Phone:330-491-9400
Practice Address - Fax:330-492-1263
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3745103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical