Healthcare Provider Details

I. General information

NPI: 1871468157
Provider Name (Legal Business Name): BROOKE HENDERSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S SPRING ST
TUPELO MS
38804-4853
US

IV. Provider business mailing address

PO BOX 68
TUPELO MS
38802-0068
US

V. Phone/Fax

Practice location:
  • Phone: 662-205-0098
  • Fax: 662-495-4079
Mailing address:
  • Phone: 622-205-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10801
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: