Provider Demographics
NPI:1831745611
Name:HENDERSON, TINA LUCILLE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LUCILLE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1981 SCRATCH GRAVEL RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-7015
Mailing Address - Country:US
Mailing Address - Phone:276-780-4946
Mailing Address - Fax:
Practice Address - Street 1:1114 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-5014
Practice Address - Country:US
Practice Address - Phone:276-883-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178041364SP0813X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0813XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Geropsychiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024178041OtherBOARD OF NURSING
VA0024178041OtherLICENSE