Provider Demographics
NPI:1770176018
Name:HENDERSON, CASSANDRA (CAREGIVER)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CAREGIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 MARCEAU DR
Mailing Address - Street 2:
Mailing Address - City:CONLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30288-1979
Mailing Address - Country:US
Mailing Address - Phone:470-253-5944
Mailing Address - Fax:
Practice Address - Street 1:1715 MARCEAU DR
Practice Address - Street 2:
Practice Address - City:CONLEY
Practice Address - State:GA
Practice Address - Zip Code:30288-1979
Practice Address - Country:US
Practice Address - Phone:470-253-5944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty