Provider Demographics
NPI:1962740035
Name:HENDERSON, MYRA ANITA (LISW-SUPV)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:ANITA
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LISW-SUPV
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:A
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3707 BELMONT RD
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4509
Mailing Address - Country:US
Mailing Address - Phone:216-299-0398
Mailing Address - Fax:
Practice Address - Street 1:29343 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1958
Practice Address - Country:US
Practice Address - Phone:216-299-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0007669 SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical