Provider Demographics
NPI:1871188490
Name:HENDERSON, SALLIE NONETTE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SALLIE
Middle Name:NONETTE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325TH MDG
Mailing Address - Street 2:340 MAGNOLIA CIRCLE
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403-5604
Mailing Address - Country:US
Mailing Address - Phone:850-283-7511
Mailing Address - Fax:
Practice Address - Street 1:325 MDG
Practice Address - Street 2:340 MAGNOLIA CIRCLE
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32404
Practice Address - Country:US
Practice Address - Phone:850-283-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW008894104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker