Provider Demographics
NPI:1558705962
Name:HENDERSON, DAMON
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 W CHEYENNE AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-3476
Mailing Address - Country:US
Mailing Address - Phone:702-683-0448
Mailing Address - Fax:702-629-7952
Practice Address - Street 1:4107 W CHEYENNE AVE STE 109
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-3476
Practice Address - Country:US
Practice Address - Phone:702-683-0448
Practice Address - Fax:702-629-7952
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV102617103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst