Provider Demographics
NPI:1659146611
Name:HENDERSON, TASHA
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 WOODLANE RD STE 23
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037
Mailing Address - Country:US
Mailing Address - Phone:866-362-4769
Mailing Address - Fax:607-704-4992
Practice Address - Street 1:702 E LAKE FRONT CIR
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-3316
Practice Address - Country:US
Practice Address - Phone:609-437-3962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health