Healthcare Provider Details

I. General information

NPI: 1689623969
Provider Name (Legal Business Name): TARYLL HENDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E MADISON ST
SOUTH BEND IN
46617-2322
US

IV. Provider business mailing address

332 N WENGER AVE
MISHAWAKA IN
46544-2522
US

V. Phone/Fax

Practice location:
  • Phone: 574-283-1107
  • Fax: 574-283-1131
Mailing address:
  • Phone: 574-259-1014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004814A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: