Basic Information
| Provider Information | |||||||||
| NPI: | 1114445293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENCEROTH | ||||||||
| FirstName: | CINDY | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW, ATR/BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 N SUNDALE RD | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437679766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403199665 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2540 BILLINGSLEY RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432351990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146026473 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | S.0177733 | OH | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 171M00000X | 05 | OH | MEDICAID | 171M000000X | 05 | OH | MEDICAID |