Provider Demographics
NPI:1063901718
Name:HENDERSON, JUDY
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 N 3RD ST STE 301
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4137
Mailing Address - Country:US
Mailing Address - Phone:215-880-7972
Mailing Address - Fax:215-893-5437
Practice Address - Street 1:461 N 3RD ST STE 301
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-4137
Practice Address - Country:US
Practice Address - Phone:215-880-7972
Practice Address - Fax:215-893-5437
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ3-0010745104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker