Provider Demographics
NPI:1437564697
Name:HENDERSON, CHARLES TODD (EDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:TODD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36037-1416
Mailing Address - Country:US
Mailing Address - Phone:334-414-1408
Mailing Address - Fax:334-382-7202
Practice Address - Street 1:106 STEWART AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-1416
Practice Address - Country:US
Practice Address - Phone:334-414-1408
Practice Address - Fax:334-382-7202
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2252A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional