Provider Demographics
NPI:1194045468
Name:HENDERSON, GENE (CAC3, NCAC2)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CAC3, NCAC2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15595 COPPERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3526
Mailing Address - Country:US
Mailing Address - Phone:719-380-1644
Mailing Address - Fax:
Practice Address - Street 1:6270 LEHMAN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1469
Practice Address - Country:US
Practice Address - Phone:719-380-1644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2345101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health