Provider Demographics
NPI:1497878177
Name:HENDERSON, THERESA C (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:C
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 W 3RD ST
Mailing Address - Street 2:SUITE 815-E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-652-3055
Mailing Address - Fax:310-652-0738
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 815-E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-652-3055
Practice Address - Fax:310-652-0738
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29057Medicare UPIN