Healthcare Provider Details

I. General information

NPI: 1033032131
Provider Name (Legal Business Name): AVA MARION HENDERSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BROADWAY ST
GLOVERSVILLE NY
12078-3968
US

IV. Provider business mailing address

11 BROADWAY ST
GLOVERSVILLE NY
12078-3968
US

V. Phone/Fax

Practice location:
  • Phone: 518-725-4310
  • Fax:
Mailing address:
  • Phone: 518-725-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number132511
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: