Provider Demographics
NPI:1568751279
Name:HENDERSON, LISA TAMAR (RASAC II)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:TAMAR
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RASAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957-1301
Mailing Address - Country:US
Mailing Address - Phone:573-208-5129
Mailing Address - Fax:573-223-7691
Practice Address - Street 1:306 N 2ND ST
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1301
Practice Address - Country:US
Practice Address - Phone:573-208-5129
Practice Address - Fax:573-223-7691
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5974101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)