Provider Demographics
NPI:1659641603
Name:HENDRICKS, GEORGEANN THELMA (LMSW, LISAC)
Entity Type:Individual
Prefix:MS
First Name:GEORGEANN
Middle Name:THELMA
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:LMSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SAN CARLOS AVE.
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-9900
Mailing Address - Country:US
Mailing Address - Phone:928-475-4875
Mailing Address - Fax:928-475-4880
Practice Address - Street 1:5 SAN CARLOS AVE.
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550-9900
Practice Address - Country:US
Practice Address - Phone:928-475-4875
Practice Address - Fax:928-475-4880
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10819101YA0400X
AZLMSW-11182104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker