Provider Demographics
NPI:1245410323
Name:HENDERSON, CORNELIUS (DPT)
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 KATY FORT BEND RD APT 5106
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-4797
Mailing Address - Country:US
Mailing Address - Phone:281-900-9430
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:601-605-8869
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA3890225200000X
TX1301027225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant