Provider Demographics
NPI:1831362839
Name:HENSON, LORETTA PEARLE (PHD, LP)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:PEARLE
Last Name:HENSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:PEARLE
Other - Last Name:LONGSDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LP
Mailing Address - Street 1:123 W CASCADE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-2222
Mailing Address - Country:US
Mailing Address - Phone:715-426-4967
Mailing Address - Fax:715-426-0985
Practice Address - Street 1:123 W CASCADE AVE
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-2222
Practice Address - Country:US
Practice Address - Phone:715-426-4967
Practice Address - Fax:715-426-0985
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2135-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39766700Medicaid
WI39766700Medicaid