MEDICARE: CONSTANCE M. HENDERSON L.C.S.W.

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	1041C0700X	Clinical Social Worker	LCS 18786	CA

General Provider Information

NPI Number	:	1629166475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONSTANCE M. HENDERSON L.C.S.W.

Provider Business Mailing Address
First Line	:	PO BOX 284
Second Line	:
City	:	LEE VINING
State	:	CA
Zip	:	93541-0284
Country	:	US
Telephone Number	:	760-934-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	549 OLD MAMMOTH ROAD, SUITE 10
Second Line	:
City	:	MAMMOTH LAKES
State	:	CA
Zip	:	93546-0000
Country	:	US
Telephone Number	:	760-934-4400
Fax Number	:

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	02/01/2008

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