MEDICARE: MICHAEL LARRY HENDERSON LCSW

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	16968	CA
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8914	OTHER	CA	MEDI-CAL BILLING NUMBER

General Provider Information

NPI Number	:	1780759340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LARRY HENDERSON LCSW

Provider Business Mailing Address
First Line	:	1650 MISSION ST STE 218
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94103-2414
Country	:	US
Telephone Number	:	415-355-3602
Fax Number	:	415-355-2355

Provider Business Practice Location Address
First Line	:	1650 MISSION ST STE 218
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94103-2414
Country	:	US
Telephone Number	:	415-355-3602
Fax Number	:	415-355-2355

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	12/26/2017

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