Provider Demographics
NPI:1275726614
Name:THE HENDERSON CLINIC LLC
Entity Type:Organization
Organization Name:THE HENDERSON CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:CONNELL
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-572-8686
Mailing Address - Street 1:359 TOWNE CENTER BLVD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4868
Mailing Address - Country:US
Mailing Address - Phone:601-572-8686
Mailing Address - Fax:601-572-8685
Practice Address - Street 1:359 TOWNE CENTER BLVD
Practice Address - Street 2:SUITE 601
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4868
Practice Address - Country:US
Practice Address - Phone:601-572-8686
Practice Address - Fax:601-572-8685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)