Basic Information
| Provider Information | |||||||||
| NPI: | 1871188490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | SALLIE | ||||||||
| MiddleName: | NONETTE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325TH MDG | ||||||||
| Address2: | 340 MAGNOLIA CIRCLE | ||||||||
| City: | TYNDALL AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324035604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502837511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 325 MDG | ||||||||
| Address2: | 340 MAGNOLIA CIRCLE | ||||||||
| City: | TYNDALL AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502837511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2021 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | MSW008894 | GA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.