Provider Demographics
NPI:1003247958
Name:HENDERSON, GREGORY (LADC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-1126
Mailing Address - Country:US
Mailing Address - Phone:802-728-4466
Mailing Address - Fax:802-728-4197
Practice Address - Street 1:39 FOGG FARM ROAD
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:VT
Practice Address - Zip Code:05088
Practice Address - Country:US
Practice Address - Phone:802-295-1311
Practice Address - Fax:802-295-1312
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT00608101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)