Provider Demographics
NPI:1104342096
Name:HENDERSON, KAYLENE SCHOLL (MA)
Entity type:Individual
Prefix:
First Name:KAYLENE
Middle Name:SCHOLL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 SUNFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-5120
Mailing Address - Country:US
Mailing Address - Phone:706-455-9028
Mailing Address - Fax:
Practice Address - Street 1:52 SUNFLOWER CT
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-3054
Practice Address - Country:US
Practice Address - Phone:706-455-9028
Practice Address - Fax:706-455-9028
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No253J00000XAgenciesFoster Care Agency
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)