Provider Demographics
NPI:1558787630
Name:HENDERSON, AMELIA
Entity Type:Individual
Prefix:
First Name:AMELIA
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 1:11428 E 20TH ST
Mailing Address - Street 2:A
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-6451
Mailing Address - Country:US
Mailing Address - Phone:918-878-7877
Mailing Address - Fax:
Practice Address - Street 1:11428 E 20TH ST
Practice Address - Street 2:A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-6451
Practice Address - Country:US
Practice Address - Phone:918-878-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health