Healthcare Provider Details

I. General information

NPI: 1780759340
Provider Name (Legal Business Name): MICHAEL LARRY HENDERSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 MISSION ST STE 218
SAN FRANCISCO CA
94103-2414
US

IV. Provider business mailing address

1650 MISSION ST STE 218
SAN FRANCISCO CA
94103-2414
US

V. Phone/Fax

Practice location:
  • Phone: 415-355-3602
  • Fax: 415-355-2355
Mailing address:
  • Phone: 415-355-3602
  • Fax: 415-355-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16968
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: