Provider Demographics
NPI:1235309394
Name:HENDERSON, KATHY A (CAC-1)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CAC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19941 GALLAGHER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1655
Mailing Address - Country:US
Mailing Address - Phone:313-331-8990
Mailing Address - Fax:313-331-6375
Practice Address - Street 1:19941 GALLAGHER ST.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1655
Practice Address - Country:US
Practice Address - Phone:313-331-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-00030324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility