Provider Demographics
NPI:1619287331
Name:HENDERSON, PAUL D (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 NW 80TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1158
Mailing Address - Country:US
Mailing Address - Phone:580-510-9811
Mailing Address - Fax:
Practice Address - Street 1:2501 NW 80TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-1158
Practice Address - Country:US
Practice Address - Phone:580-510-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2887235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist