Provider Demographics
NPI:1356023683
Name:HENDERSON, DEIDRE M
Entity type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:M
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:PO BOX 8776
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06531-0776
Mailing Address - Country:US
Mailing Address - Phone:203-627-8728
Mailing Address - Fax:203-437-8119
Practice Address - Street 1:62 CALUMET ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1201
Practice Address - Country:US
Practice Address - Phone:203-627-8728
Practice Address - Fax:203-437-8119
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT145104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker