Provider Demographics
NPI:1043746282
Name:HENDERSON, ELLIOT J (PHD)
Entity Type:Individual
Prefix:MR
First Name:ELLIOT
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 HYDE STREET
Mailing Address - Street 2:SUITE 428
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109
Mailing Address - Country:US
Mailing Address - Phone:415-563-5566
Mailing Address - Fax:415-563-5558
Practice Address - Street 1:909 HYDE STREET
Practice Address - Street 2:SUITE 428
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109
Practice Address - Country:US
Practice Address - Phone:415-563-5566
Practice Address - Fax:415-563-5558
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8809103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist