Basic Information
| Provider Information | |||||||||
| NPI: | 1003452640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | JOHNASTASIA | ||||||||
| MiddleName: | LILLIAN | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 LIBERTY ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011031109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132717136 | ||||||||
| FaxNumber: | 4132717137 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 OAK AVE | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7744028800 | ||||||||
| FaxNumber: | 7744202804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2019 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.