Provider Demographics
NPI:1881184182
Name:HENDERSON, GRACE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HESTON ST APT 131
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-1292
Mailing Address - Country:US
Mailing Address - Phone:903-215-0555
Mailing Address - Fax:
Practice Address - Street 1:701 E MARSHALL AVE STE 310
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5544
Practice Address - Country:US
Practice Address - Phone:903-234-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75995101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional