Provider Demographics
NPI:1407940083
Name:HENDERSHOTT, MARY (LISW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HENDERSHOTT
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 KIMBERLY RD.
Mailing Address - Street 2:#165 SOUTH
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722
Mailing Address - Country:US
Mailing Address - Phone:563-362-2848
Mailing Address - Fax:
Practice Address - Street 1:2435 KIMBERLY RD
Practice Address - Street 2:STE 165S
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3591
Practice Address - Country:US
Practice Address - Phone:563-362-2848
Practice Address - Fax:563-888-5160
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05287104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA218643OtherHEALTH ALLIANCE MEDICARE
IAI18118OtherMEDICARE ID
IA0283507Medicaid