Provider Demographics
NPI:1053328963
Name:HENDRICK, MITZI SEYMOUR (LCSW)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:SEYMOUR
Last Name:HENDRICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0564
Mailing Address - Country:US
Mailing Address - Phone:434-447-2595
Mailing Address - Fax:434-447-2556
Practice Address - Street 1:514 E ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-2704
Practice Address - Country:US
Practice Address - Phone:434-447-2595
Practice Address - Fax:434-447-2556
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040021671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008933103Medicaid
VA008933103Medicaid