Provider Demographics
NPI:1619009669
Name:STATHAM, HENRIETTA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:HENRIETTA
Middle Name:
Last Name:STATHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 S 8TH ST
Mailing Address - Street 2:4A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-6167
Mailing Address - Country:US
Mailing Address - Phone:718-387-3986
Mailing Address - Fax:
Practice Address - Street 1:143 S 8TH ST
Practice Address - Street 2:4A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-6167
Practice Address - Country:US
Practice Address - Phone:718-387-3986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0704931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical