Provider Demographics
NPI:1578534756
Name:HENDERSON, BRENT N (PHD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:N
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HOT METAL ST
Mailing Address - Street 2:QUANTUM ONE, N430
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15203-2348
Mailing Address - Country:US
Mailing Address - Phone:412-432-7706
Mailing Address - Fax:412-432-7691
Practice Address - Street 1:5115 CENTRE AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1301
Practice Address - Country:US
Practice Address - Phone:412-623-5888
Practice Address - Fax:412-623-5980
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015211103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA520447Medicaid
PA11440288OtherCAQH
PA001905341Medicaid
PA11440288OtherCAQH
PA001905341Medicaid
PA059785QEJMedicare PIN
PAP00430141Medicare PIN