Provider Demographics
NPI:1306478383
Name:HENRY, SELENA (LCSW)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 W MAXWELL ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-5000
Mailing Address - Country:US
Mailing Address - Phone:312-413-2687
Mailing Address - Fax:
Practice Address - Street 1:715 W MAXWELL ST STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-5000
Practice Address - Country:US
Practice Address - Phone:312-413-2687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490191911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical