Provider Demographics
NPI:1346772589
Name:HENDERSON, ROBERT R
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CRITTENDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8409
Mailing Address - Country:US
Mailing Address - Phone:585-275-3563
Mailing Address - Fax:585-276-2292
Practice Address - Street 1:1360 CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4135
Practice Address - Country:US
Practice Address - Phone:678-825-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 390200000X, 101YM0800X
FLPY11285103TC0700X
GAPSY004688103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program