Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
N | 101YM0800X | Mental Health Counselor |
NPI | 1003452640 |
---|---|
Provider Name | Johnastasia Lillian Henderson |
First Address | Springfield, MA 01103-1109 |
Second Address | Worcester, MA 01605-2752 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/11/2019 |
Last Update Date | 19/11/2019 |