Provider Demographics
NPI:1770698565
Name:HENDERSON, MICHAEL JAMES (LCSW LICENSED CLINIC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LCSW LICENSED CLINIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 LAKESHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-756-0794
Mailing Address - Fax:
Practice Address - Street 1:433 MAIN
Practice Address - Street 2:SUITE 4B
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-756-0794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT320LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0501432Medicaid
MT0704115OtherBLUE CROSS BLUE SHIELD
P00295420OtherMEDICARE RAILROAD