Provider Demographics
NPI:1902013774
Name:HENNEBERRY, DENISE COPPOLA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:COPPOLA
Last Name:HENNEBERRY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DENISE
Other - Middle Name:LYN
Other - Last Name:COPPOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:451 ANDOVER ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-5044
Mailing Address - Country:US
Mailing Address - Phone:617-388-7182
Mailing Address - Fax:
Practice Address - Street 1:451 ANDOVER ST
Practice Address - Street 2:SUITE 301
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-5044
Practice Address - Country:US
Practice Address - Phone:617-388-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8868103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical