Provider Demographics
NPI:1295511020
Name:HENDERSON, AMANDA ELIZABETH
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20500 EUREKA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6394
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 GENOA BUSINESS PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-5328
Practice Address - Country:US
Practice Address - Phone:517-882-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010966181041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool