Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 149016029 | IL |
NPI | 1003247115 |
---|---|
Provider Name | Mrs. Amanda B Henson |
First Address | Springfield, IL 62703-2312 |
Second Address | Springfield, IL 62703-2312 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2013 |
Last Update Date | 29/11/2013 |