Provider Demographics
NPI:1235886342
Name:HENDERSON, ANGELA M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:M
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10755 S SEELEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3314
Mailing Address - Country:US
Mailing Address - Phone:312-752-6289
Mailing Address - Fax:
Practice Address - Street 1:1987 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4247
Practice Address - Country:US
Practice Address - Phone:773-238-1100
Practice Address - Fax:773-238-4095
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041245406163WP0808X
IL209.025817363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health