Provider Demographics
NPI:1255956942
Name:HENDERSON, KIMBERLY MICHELLE (LSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:321 W JEFFERSON ST APT 6
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1024
Mailing Address - Country:US
Mailing Address - Phone:815-768-0012
Mailing Address - Fax:
Practice Address - Street 1:6392 LINDEN RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2816
Practice Address - Country:US
Practice Address - Phone:779-368-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108278104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker