Provider Demographics
NPI:1235289810
Name:HENDERSON, LAURA S (MSW CSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MSW CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 S HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2141
Mailing Address - Country:US
Mailing Address - Phone:586-219-0504
Mailing Address - Fax:
Practice Address - Street 1:43200 DEQUINDRE RD
Practice Address - Street 2:STE 104
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1707
Practice Address - Country:US
Practice Address - Phone:586-799-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010684251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M10270036Medicare ID - Type Unspecified