Provider Demographics
NPI:1164069829
Name:HENDERSON, DAVETTA A (PSYD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:DAVETTA
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PSYD, LMHC
Other - Prefix:DR
Other - First Name:DAVETTA
Other - Middle Name:A
Other - Last Name:CARLISLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CARLISLE
Mailing Address - Street 1:1800 N MERIDIAN ST STE 505
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1433
Mailing Address - Country:US
Mailing Address - Phone:317-464-3515
Mailing Address - Fax:
Practice Address - Street 1:4115 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3614
Practice Address - Country:US
Practice Address - Phone:817-796-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003653A101YM0800X
TX91192101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health