Basic Information
| Provider Information | |||||||||
| NPI: | 1134727704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | IDA | ||||||||
| MiddleName: | NATASHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 SUNVIEW LN | ||||||||
| Address2: | |||||||||
| City: | STONEWALL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710788420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182057977 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2219 CLAIBORNE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187790434 | ||||||||
| FaxNumber: | 3182100000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2020 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.