MEDICARE: MRS. MYRA ANITA HENDERSON LISW-SUPV

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	I0007669 SUPV	OH

General Provider Information

NPI Number	:	1962740035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MYRA ANITA HENDERSON LISW-SUPV

Provider Business Mailing Address
First Line	:	3707 BELMONT RD
Second Line	:
City	:	WOODMERE
State	:	OH
Zip	:	44122-4509
Country	:	US
Telephone Number	:	216-299-0398
Fax Number	:

Provider Business Practice Location Address
First Line	:	29343 EUCLID AVE
Second Line	:
City	:	WICKLIFFE
State	:	OH
Zip	:	44092-1958
Country	:	US
Telephone Number	:	216-299-0398
Fax Number	:

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

Provider Enumeration Date	:	01/24/2013
Last Update Date	:	03/17/2018

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