MEDICARE: COREY HENDERSON LPC, NCC

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	101YM0800X	Mental Health Counselor	LPC 10514	NC

General Provider Information

NPI Number	:	1508212325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY HENDERSON LPC, NCC

Provider Business Mailing Address
First Line	:	2732 N DAVIDSON ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1043
Country	:	US
Telephone Number	:	980-275-2482
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 S SHARON AMITY RD
Second Line	:	SUITE 500
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2896
Country	:	US
Telephone Number	:	980-275-2482
Fax Number	:

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

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	03/01/2017

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