Provider Demographics
NPI:1518324607
Name:HENDERSON, DARRETH H (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:DARRETH
Middle Name:H
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E BAKER ST
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2450
Mailing Address - Country:US
Mailing Address - Phone:662-635-7310
Mailing Address - Fax:
Practice Address - Street 1:121 E BAKER ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2450
Practice Address - Country:US
Practice Address - Phone:662-635-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist