Provider Demographics
NPI:1316015647
Name:HENDERSON, CAROLYN J (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 MINNI TOHE DR
Mailing Address - Street 2:MINNE TOHE HEALTH CENTER
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763-4400
Mailing Address - Country:US
Mailing Address - Phone:701-627-4701
Mailing Address - Fax:701-627-2810
Practice Address - Street 1:1 MINNI TOHE DR
Practice Address - Street 2:MINNE TOHE HEALTH CENTER
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763-4400
Practice Address - Country:US
Practice Address - Phone:701-627-4701
Practice Address - Fax:701-627-2810
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND32531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDQ41056Medicare UPIN