Provider Demographics
NPI:1588629752
Name:HENDERSON, SUSAN CARROLL (M ED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:CARROLL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BOONSBORO DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2102
Mailing Address - Country:US
Mailing Address - Phone:434-384-0206
Mailing Address - Fax:
Practice Address - Street 1:2316 ATHERHOLT RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2100
Practice Address - Country:US
Practice Address - Phone:434-528-0184
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002960101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11526313OtherCAQH
VA5410657Medicaid
VA5410282Medicaid