Provider Demographics
NPI:1275213142
Name:HENDERSON, MECHELLE LADELL
Entity Type:Individual
Prefix:
First Name:MECHELLE
Middle Name:LADELL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MECHELLE
Other - Middle Name:LADELL
Other - Last Name:MOODY HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15052 ROCHELLE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-4432
Mailing Address - Country:US
Mailing Address - Phone:614-589-5277
Mailing Address - Fax:
Practice Address - Street 1:15052 ROCHELLE DR
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-4432
Practice Address - Country:US
Practice Address - Phone:614-589-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT482570172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver