Provider Demographics
NPI:1386898849
Name:HENDERSON, SUSAN CAROL (MED, LPC, LMFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MED, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S WATTERS RD STE 133
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5225
Mailing Address - Country:US
Mailing Address - Phone:972-654-8918
Mailing Address - Fax:214-856-5817
Practice Address - Street 1:550 S WATTERS RD STE 133
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5225
Practice Address - Country:US
Practice Address - Phone:972-654-8918
Practice Address - Fax:214-856-5817
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4351106H00000X
TX11092101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX026280001Medicaid