Provider Demographics
NPI:1376748483
Name:HENDERSHOT, TAMARA (MSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:HENDERSHOT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 WOODWARD ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18705-3100
Mailing Address - Country:US
Mailing Address - Phone:570-262-0256
Mailing Address - Fax:
Practice Address - Street 1:307 LAIRD ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6915
Practice Address - Country:US
Practice Address - Phone:570-408-9320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone