MEDICARE: MS. MARY KATHLEEN HENDERSON LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	NH0125	NH

General Provider Information

NPI Number	:	1225547508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KATHLEEN HENDERSON LADC

Provider Business Mailing Address
First Line	:	PO BOX 431
Second Line	:
City	:	EAST HAMPSTEAD
State	:	NH
Zip	:	03826-0431
Country	:	US
Telephone Number	:	503-560-2854
Fax Number	:

Provider Business Practice Location Address
First Line	:	393 MAIN ST
Second Line	:
City	:	DANVILLE
State	:	NH
Zip	:	03819-3219
Country	:	US
Telephone Number	:	603-560-2854
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2017
Last Update Date	:	09/29/2017

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