Provider Demographics
NPI:1356958334
Name:HENDERSON, ILISA (MSW LCSWA)
Entity type:Individual
Prefix:MRS
First Name:ILISA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MSW LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 PINTAIL PL APT 105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1912
Mailing Address - Country:US
Mailing Address - Phone:609-472-9864
Mailing Address - Fax:
Practice Address - Street 1:714 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-5412
Practice Address - Country:US
Practice Address - Phone:866-495-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0145181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical