Provider Demographics
NPI:1558702035
Name:HENDERSON, DELORES CLACK
Entity Type:Individual
Prefix:MRS
First Name:DELORES
Middle Name:CLACK
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MISTY FAWN LN
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-9502
Mailing Address - Country:US
Mailing Address - Phone:713-410-0475
Mailing Address - Fax:
Practice Address - Street 1:1615 MISTY FAWN LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-9502
Practice Address - Country:US
Practice Address - Phone:713-410-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT01206133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered