Basic Information
| Provider Information | |||||||||
| NPI: | 1831462696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 PEARL ST | ||||||||
| Address2: | APT 2 | ||||||||
| City: | MIDDLEBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023462231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7742139118 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023017501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
| FaxNumber: | 5085805162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2012 | ||||||||
| LastUpdateDate: | 02/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.