Provider Demographics
NPI:1831462696
Name:HENDERSON, MICHELLE P
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:P
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 1:8 PEARL ST
Mailing Address - Street 2:APT 2
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346-2231
Mailing Address - Country:US
Mailing Address - Phone:774-213-9118
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:508-580-5162
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program