Provider Demographics
NPI:1710331822
Name:HENDERSON, CAROL A
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:A
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 1:24 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2810
Mailing Address - Country:US
Mailing Address - Phone:276-632-7128
Mailing Address - Fax:276-632-0995
Practice Address - Street 1:30 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-3008
Practice Address - Country:US
Practice Address - Phone:540-483-5044
Practice Address - Fax:276-632-0995
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006515101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional