Provider Demographics
NPI:1982979662
Name:THERESA M HENDERSON, PA
Entity Type:Organization
Organization Name:THERESA M HENDERSON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-716-0585
Mailing Address - Street 1:9609 WOODBAY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2422
Mailing Address - Country:US
Mailing Address - Phone:813-716-0585
Mailing Address - Fax:813-814-0448
Practice Address - Street 1:1210 MILLENNIUM PKWY
Practice Address - Street 2:SUITE 1035
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4861
Practice Address - Country:US
Practice Address - Phone:813-716-0585
Practice Address - Fax:813-814-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-14
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW20721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty