Healthcare Provider Details

I. General information

NPI: 1982979662
Provider Name (Legal Business Name): THERESA M HENDERSON, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 MILLENNIUM PKWY SUITE 1035
BRANDON FL
33511-4861
US

IV. Provider business mailing address

9609 WOODBAY DR
TAMPA FL
33626-2422
US

V. Phone/Fax

Practice location:
  • Phone: 813-716-0585
  • Fax: 813-814-0448
Mailing address:
  • Phone: 813-716-0585
  • Fax: 813-814-0448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW2072
License Number StateFL

VIII. Authorized Official

Name: MS. THERESA M HENDERSON
Title or Position: PRESIDENT
Credential: LCSW
Phone: 813-716-0585