Healthcare Provider Details

I. General information

NPI: 1235886342
Provider Name (Legal Business Name): ANGELA M HENDERSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1987 W 111TH ST
CHICAGO IL
60643-4247
US

IV. Provider business mailing address

10755 S SEELEY AVE
CHICAGO IL
60643-3314
US

V. Phone/Fax

Practice location:
  • Phone: 773-238-1100
  • Fax: 773-238-4095
Mailing address:
  • Phone: 312-752-6289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.025817
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041245406
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: