Provider Demographics
NPI:1093443400
Name:HENDERSON, RODNEY (SUDCC 8482)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:SUDCC 8482
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-3808
Mailing Address - Country:US
Mailing Address - Phone:323-325-7510
Mailing Address - Fax:
Practice Address - Street 1:5320 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3808
Practice Address - Country:US
Practice Address - Phone:323-325-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASUDCC8482101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)