Provider Demographics
NPI:1801031539
Name:HENDERSON, TISSIA FAY
Entity Type:Individual
Prefix:
First Name:TISSIA
Middle Name:FAY
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 1:11222 TURFGRASS WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8303
Mailing Address - Country:US
Mailing Address - Phone:317-826-6328
Mailing Address - Fax:
Practice Address - Street 1:8902 OTIS AVE STE 105B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-1076
Practice Address - Country:US
Practice Address - Phone:317-414-4126
Practice Address - Fax:317-723-3615
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090164A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health