Provider Demographics
NPI:1558727941
Name:HENDERSON, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
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 1:1050 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5400
Mailing Address - Country:US
Mailing Address - Phone:843-549-8899
Mailing Address - Fax:
Practice Address - Street 1:2004 JEFFERIES HWYV
Practice Address - Street 2:
Practice Address - City:WALTERBORI
Practice Address - State:SC
Practice Address - Zip Code:29488
Practice Address - Country:US
Practice Address - Phone:843-549-6536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576000922OtherBEHAVIORAL HEATH AND SOCIAL SERVICE PROVIDERS