Provider Demographics
NPI:1558099739
Name:HENDERSON, MARISSA
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:
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 1:13066 SANDBOURNE N
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7508
Mailing Address - Country:US
Mailing Address - Phone:413-896-7612
Mailing Address - Fax:
Practice Address - Street 1:118 MABRY HOOD RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2219
Practice Address - Country:US
Practice Address - Phone:865-982-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical