Provider Demographics
NPI:1225847635
Name:HENDERSON, GLORI MAE (QMHP,ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:GLORI
Middle Name:MAE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:QMHP,ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4243 LAKE WOODARD DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1071
Mailing Address - Country:US
Mailing Address - Phone:984-289-7325
Mailing Address - Fax:
Practice Address - Street 1:2013 N ARMISTEAD AVE APT E16
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3499
Practice Address - Country:US
Practice Address - Phone:984-289-7325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-01
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0734012512101YM0800X
NC76840164X00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse