Provider Demographics
NPI:1346904562
Name:HENDERSON, BRANDY NICHOLE (MA, PLPC)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICHOLE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1569 NORLAKES DR APT C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1849
Mailing Address - Country:US
Mailing Address - Phone:314-683-5730
Mailing Address - Fax:
Practice Address - Street 1:2705 MULLANPHY LN
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-3727
Practice Address - Country:US
Practice Address - Phone:314-830-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YP2500X
MO2021040533101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional