Provider Demographics
NPI:1518747864
Name:HENDERSON, CHERYL MADONNA
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:MADONNA
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 214TH PL
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2123
Mailing Address - Country:US
Mailing Address - Phone:718-229-5757
Mailing Address - Fax:717-939-0881
Practice Address - Street 1:3909 214TH PL
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2123
Practice Address - Country:US
Practice Address - Phone:718-229-5757
Practice Address - Fax:717-939-0881
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR052654-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty