Provider Demographics
NPI:1700570413
Name:HENDERSON, ELENA KELSEY (PHD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:KELSEY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W 1300 S UNIT 10
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5586
Mailing Address - Country:US
Mailing Address - Phone:801-436-4336
Mailing Address - Fax:
Practice Address - Street 1:912 S WOOD ST # 838
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4300
Practice Address - Country:US
Practice Address - Phone:312-413-1567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13007086-2501103TC0700X
IL071.011031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical