Provider Demographics
NPI:1821748468
Name:HENSON, KATIE NICHOL
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:NICHOL
Last Name:HENSON
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 1:907 MIMOSA WAY
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-5115
Mailing Address - Country:US
Mailing Address - Phone:321-262-4343
Mailing Address - Fax:
Practice Address - Street 1:907 MIMOSA WAY
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-5115
Practice Address - Country:US
Practice Address - Phone:321-262-4343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-26
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20493103TC1900X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling