Healthcare Provider Details

I. General information

NPI: 1891075081
Provider Name (Legal Business Name): DENESE WALTERS HENDERSON MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DENESE WALERS MFT

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 N OAK STREET EXT BLDG D
VALDOSTA GA
31605-1066
US

IV. Provider business mailing address

3312 N OAK STREET EXT BLDG D
VALDOSTA GA
31605-1066
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-2030
  • Fax: 229-244-2038
Mailing address:
  • Phone: 229-244-2030
  • Fax: 229-244-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001208
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000196
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: