Provider Demographics
NPI:1265096119
Name:HENDERSON, DIAMOND (LCMHCA)
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 MAGNOLIA BRANCH DR APT 10
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4409
Mailing Address - Country:US
Mailing Address - Phone:404-513-2306
Mailing Address - Fax:
Practice Address - Street 1:3816 N ELM ST STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2776
Practice Address - Country:US
Practice Address - Phone:336-545-5995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14776101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional