Healthcare Provider Details

I. General information

NPI: 1649789504
Provider Name (Legal Business Name): MICHAEL HENDERSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2017
Last Update Date: 09/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 BYRD AVE STE 200
RICHMOND VA
23230-3033
US

IV. Provider business mailing address

1900 BYRD AVE STE 200
RICHMOND VA
23230-3033
US

V. Phone/Fax

Practice location:
  • Phone: 804-592-6311
  • Fax: 804-237-0532
Mailing address:
  • Phone: 804-592-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007163
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: