Provider Demographics
NPI:1306188685
Name:HENDERSON, LAWANDA L
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19925 E 44TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8224
Mailing Address - Country:US
Mailing Address - Phone:918-951-3455
Mailing Address - Fax:918-355-5734
Practice Address - Street 1:19925 E 44TH ST S
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-8224
Practice Address - Country:US
Practice Address - Phone:918-951-3455
Practice Address - Fax:918-355-5734
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20028712GAMedicaid