Provider Demographics
NPI:1831675453
Name:HENDERSON, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
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 1:110 WURST CT
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5611
Mailing Address - Country:US
Mailing Address - Phone:440-865-6623
Mailing Address - Fax:
Practice Address - Street 1:12 E EXCHANGE ST FL 6
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1541
Practice Address - Country:US
Practice Address - Phone:234-334-3293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid