Provider Demographics
NPI:1790829968
Name:HENDERSON, SALLY JEAN (PHD LMFT LMSW)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:JEAN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD LMFT LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 WESTBURY DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-2723
Mailing Address - Country:US
Mailing Address - Phone:319-356-6352
Mailing Address - Fax:319-358-2367
Practice Address - Street 1:673 WESTBURY DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-2723
Practice Address - Country:US
Practice Address - Phone:319-356-6352
Practice Address - Fax:319-358-2367
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00142106H00000X
IA04884104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA458268000Medicaid
IA232194OtherMIDLANDS CHOICE CACTUS ID