Provider Demographics
NPI:1588252688
Name:HENDERSON, LAVATOR
Entity type:Individual
Prefix:
First Name:LAVATOR
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 1:1837 BUNDY ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-1703
Mailing Address - Country:US
Mailing Address - Phone:570-815-8084
Mailing Address - Fax:
Practice Address - Street 1:1151 POCONO BLVD STE 2
Practice Address - Street 2:
Practice Address - City:MOUNT POCONO
Practice Address - State:PA
Practice Address - Zip Code:18344-1033
Practice Address - Country:US
Practice Address - Phone:570-243-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA218750101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health