Healthcare Provider Details

I. General information

NPI: 1326599663
Provider Name (Legal Business Name): LATUNDRA HENDERSON LISW, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC161330
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberS1600147
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2002418-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: