Provider Demographics
NPI:1710497888
Name:HENDERSON, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
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 1:3722 BLANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12395 MCCRACKEN RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-2967
Practice Address - Country:US
Practice Address - Phone:216-587-3727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1500375101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health