Provider Demographics
NPI:1174752364
Name:HENDERSON, TERESA D (MS, LPEI)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MS, LPEI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3117 POLK ROAD 44
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-3891
Mailing Address - Country:US
Mailing Address - Phone:479-234-1808
Mailing Address - Fax:
Practice Address - Street 1:3117 POLK ROAD 44
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-3891
Practice Address - Country:US
Practice Address - Phone:479-234-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR85-20EI103TC1900X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling