Provider Demographics
NPI:1386252500
Name:HENDERSON, SHOQUANA (BSW, RPSGT)
Entity type:Individual
Prefix:
First Name:SHOQUANA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:BSW, RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6047 BERRETTA CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6802
Mailing Address - Country:US
Mailing Address - Phone:662-420-2675
Mailing Address - Fax:
Practice Address - Street 1:6047 BERRETTA CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6802
Practice Address - Country:US
Practice Address - Phone:662-420-2675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool