Provider Demographics
NPI:1639566466
Name:HENDERSON, COLEEN (LISW-S)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 E CENTERVILLE STATION RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-5500
Mailing Address - Country:US
Mailing Address - Phone:937-241-6403
Mailing Address - Fax:937-439-2984
Practice Address - Street 1:1055 E CENTERVILLE STATION RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-5500
Practice Address - Country:US
Practice Address - Phone:937-241-6403
Practice Address - Fax:937-439-2984
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700205-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical