Provider Demographics
NPI:1619217650
Name:HENDERSON, FANITA SANDERS
Entity Type:Individual
Prefix:
First Name:FANITA
Middle Name:SANDERS
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FANITA
Other - Middle Name:
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:793 E CARL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1902
Mailing Address - Country:US
Mailing Address - Phone:516-330-0870
Mailing Address - Fax:516-705-5050
Practice Address - Street 1:100 N VILLAGE AVE
Practice Address - Street 2:SUITE 17
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3767
Practice Address - Country:US
Practice Address - Phone:516-330-0870
Practice Address - Fax:516-330-0870
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health