Provider Demographics
NPI:1518158088
Name:DENNIS M HENDERSON PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:DENNIS M HENDERSON PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:MALCOLM
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:631-368-8502
Mailing Address - Street 1:12 GILDARE DR
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3223
Mailing Address - Country:US
Mailing Address - Phone:631-368-8502
Mailing Address - Fax:631-368-8502
Practice Address - Street 1:12 GILDARE DR
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-3223
Practice Address - Country:US
Practice Address - Phone:631-368-8502
Practice Address - Fax:631-368-8502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENNIS M HENDERSON PSYCHOLOGICAL SERVICES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0117921103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01660731Medicaid
NY1639287758OtherNPI
NYR98303Medicare UPIN
NY01660731Medicare PIN
NYV9I681Medicare Oscar/Certification