Provider Demographics
NPI:1356902183
Name:HENDERSON, AMY ELIZABETH (SLP-CF)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:SLP-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W CHAPEL HILL ST APT 662
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-2776
Mailing Address - Country:US
Mailing Address - Phone:704-516-2048
Mailing Address - Fax:
Practice Address - Street 1:103 ROSEHILL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4843
Practice Address - Country:US
Practice Address - Phone:434-517-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000322235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist