Provider Demographics
NPI:1235784471
Name:HENDERSON, MARILYN GENORA (MS)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:GENORA
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MS
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 187
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-0185
Mailing Address - Country:US
Mailing Address - Phone:856-352-5424
Mailing Address - Fax:
Practice Address - Street 1:130 W WHITE HORSE PIKE STE 1B
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-2028
Practice Address - Country:US
Practice Address - Phone:856-352-5424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health