Provider Demographics
NPI:1578041729
Name:HENDERSON, KYERRA (BA MHP)
Entity Type:Individual
Prefix:
First Name:KYERRA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:BA MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:IL
Mailing Address - Zip Code:62914-1810
Mailing Address - Country:US
Mailing Address - Phone:618-734-2664
Mailing Address - Fax:618-734-1999
Practice Address - Street 1:1401 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-1810
Practice Address - Country:US
Practice Address - Phone:618-734-2664
Practice Address - Fax:618-734-1999
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health