Provider Demographics
NPI:1235280744
Name:HENDERSON, MATTHEW MORGAN (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MORGAN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4912 PERSHING PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1202
Mailing Address - Country:US
Mailing Address - Phone:210-274-6609
Mailing Address - Fax:
Practice Address - Street 1:4220 DUNCAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1103
Practice Address - Country:US
Practice Address - Phone:210-274-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1535569-01Medicaid