Provider Demographics
NPI:1609258193
Name:HENDERSON, ANGELA (MED, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 DEN CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-4624
Mailing Address - Country:US
Mailing Address - Phone:404-307-9553
Mailing Address - Fax:
Practice Address - Street 1:145 DEN CREEK TRL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-4624
Practice Address - Country:US
Practice Address - Phone:404-307-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007946235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist