Basic Information
| Provider Information | |||||||||
| NPI: | 1851580104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | LAR'MARA | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | , LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | CHATTANOOGA VA OUTPATIENT CLINIC | ||||||||
| Address2: | 6401 SHALLOWFORD ROAD | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238936500 | ||||||||
| FaxNumber: | 8009300601 | ||||||||
| Practice Location | |||||||||
| Address1: | WOMACK ARMY MEDICAL CENTER | ||||||||
| Address2: | BLDG# 4-3219 2817 REILLY ROAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109076825 | ||||||||
| FaxNumber: | 8009300601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7654 | TN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C006836 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.