Provider Demographics
NPI:1326149014
Name:HENDERSON, THERESA M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9609 WOODBAY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2422
Mailing Address - Country:US
Mailing Address - Phone:813-716-0585
Mailing Address - Fax:813-814-0448
Practice Address - Street 1:1210 MILLENNIUM PKWY
Practice Address - Street 2:SUITE 1035
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4896
Practice Address - Country:US
Practice Address - Phone:813-716-0585
Practice Address - Fax:813-814-0448
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 20721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275650000OtherMAGELLAN HEALTH SERVICES
FL5650654OtherAETNA
FL007822OtherVALUEOPTIONS
FL230056OtherUNITED BEHAVIORAL HEALTH
FL5650654OtherAETNA