Basic Information
Provider Information | |||||||||
NPI: | 1508053513 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDERSON | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MHPP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DANIELS | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3604 CENTRAL AVE | ||||||||
Address2: | SUITE C | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 71913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016239220 | ||||||||
FaxNumber: | 5016239227 | ||||||||
Practice Location | |||||||||
Address1: | 3604 CENTRAL AVE | ||||||||
Address2: | SUITE C | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 71913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016239220 | ||||||||
FaxNumber: | 5016239227 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2007 | ||||||||
LastUpdateDate: | 10/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 116399726 | 05 | AR |   | MEDICAID |