Basic Information
| Provider Information | |||||||||
| NPI: | 1881997195 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDERSON MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544973856 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 N STATE ROAD 7 STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544973856 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2010 | ||||||||
| LastUpdateDate: | 12/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | RICKETTS | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9544973856 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0625X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 141730400 | 05 | FL | MEDICAID | 141683900 | 05 | FL | MEDICAID | 141731200 | 05 | FL | MEDICAID |