Provider Demographics
NPI:1508913997
Name:HENDERSON, MICHELE ELIZABETH (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ELIZABETH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 UNION ST
Mailing Address - Street 2:SUITE 20 & 25
Mailing Address - City:S WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-2314
Mailing Address - Country:US
Mailing Address - Phone:617-786-7484
Mailing Address - Fax:
Practice Address - Street 1:33 UNION ST
Practice Address - Street 2:SUITE 20 & 25
Practice Address - City:S WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2314
Practice Address - Country:US
Practice Address - Phone:617-786-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10266421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1892908Medicaid
MA290542000Medicare UPIN
MA1892908Medicaid