Provider Demographics
NPI:1811389620
Name:HENDERSON, HOLLY JO (LPC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JO
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:CAPE FAIR
Mailing Address - State:MO
Mailing Address - Zip Code:65624-0221
Mailing Address - Country:US
Mailing Address - Phone:417-559-0135
Mailing Address - Fax:
Practice Address - Street 1:1701 TOWNSEND ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1451
Practice Address - Country:US
Practice Address - Phone:417-671-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002776101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1811389620Medicaid