MEDICARE: DIANE HENDERSON ENTERPRISES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C001733	NC

General Provider Information

NPI Number	:	1265693808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANE HENDERSON ENTERPRISES INC

Provider Business Mailing Address
First Line	:	112 N CIRCLE DRIVE
Second Line	:
City	:	ROCKY MOUNTAIN
State	:	NC
Zip	:	27804-2430
Country	:	US
Telephone Number	:	252-903-9926
Fax Number	:	252-977-6114

Provider Business Practice Location Address
First Line	:	112 N CIRCLE DRIVE
Second Line	:
City	:	ROCKY MOUNTAIN
State	:	NC
Zip	:	27804-2430
Country	:	US
Telephone Number	:	252-903-9926
Fax Number	:	252-977-6114

Authorized Official
Title or Position	:	MSW LCSW
Name	:	MS. DIANE VALENTI HENDERSON
Credential	:	MSW LCSW
Telephone Number	:	252-903-9926

Provider Enumeration Date	:	06/17/2008
Last Update Date	:	06/27/2008

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