Provider Demographics
NPI:1356686075
Name:HENDERSON, DERRICK JERMELL (MSCP)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:JERMELL
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2891 PONTIAC LOOP
Mailing Address - Street 2:
Mailing Address - City:COTTONDALE
Mailing Address - State:FL
Mailing Address - Zip Code:32431-7321
Mailing Address - Country:US
Mailing Address - Phone:850-209-9802
Mailing Address - Fax:
Practice Address - Street 1:2891 PONTIAC LOOP
Practice Address - Street 2:
Practice Address - City:COTTONDALE
Practice Address - State:FL
Practice Address - Zip Code:32431-7321
Practice Address - Country:US
Practice Address - Phone:850-209-9802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health