Healthcare Provider Details

I. General information

NPI: 1649487299
Provider Name (Legal Business Name): JANIS W HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 HIGH ST
SOUTH GLASTONBURY CT
06033-9998
US

IV. Provider business mailing address

244 WOOD POND RD
GLASTONBURY CT
06033-3704
US

V. Phone/Fax

Practice location:
  • Phone: 860-659-0183
  • Fax:
Mailing address:
  • Phone: 860-633-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001137
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: