Provider Demographics
NPI:1689893687
Name:HENDERSON, MARSHA T (LCSW)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:T
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 1:25301 CABOT RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5523
Mailing Address - Country:US
Mailing Address - Phone:949-951-9655
Mailing Address - Fax:949-951-9654
Practice Address - Street 1:25301 CABOT RD
Practice Address - Street 2:SUITE 116
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5523
Practice Address - Country:US
Practice Address - Phone:949-951-9655
Practice Address - Fax:949-951-9654
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS52541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW5254Medicare ID - Type Unspecified