MEDICARE: MR. DARON GLEN HENDERSON LMSW

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	104100000X	Social Worker	LMSW-25799	ID

General Provider Information

NPI Number	:	1770624231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARON GLEN HENDERSON LMSW

Provider Business Mailing Address
First Line	:	1285 NIXON AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-5611
Country	:	US
Telephone Number	:	208-529-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1285 NIXON AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-5611
Country	:	US
Telephone Number	:	208-529-4300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	07/08/2007

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