Provider Demographics
NPI:1629166475
Name:HENDERSON, CONSTANCE M (LCSW)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:M
Last Name:HENDERSON
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:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:LEE VINING
Mailing Address - State:CA
Mailing Address - Zip Code:93541-0284
Mailing Address - Country:US
Mailing Address - Phone:760-934-4400
Mailing Address - Fax:
Practice Address - Street 1:549 OLD MAMMOTH ROAD, SUITE 10
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-0000
Practice Address - Country:US
Practice Address - Phone:760-934-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 187861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical