Provider Demographics
NPI:1639287758
Name:HENDERSON, DENNIS MALCOLM (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MALCOLM
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 1:12 GILDARE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3223
Mailing Address - Country:US
Mailing Address - Phone:631-368-8502
Mailing Address - Fax:631-368-8502
Practice Address - Street 1:12 GILDARE DRIVE
Practice Address - Street 2:
Practice Address - City:GAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-3223
Practice Address - Country:US
Practice Address - Phone:631-368-8502
Practice Address - Fax:631-368-8502
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011792-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01660737Medicaid
NYS11729-9OtherWORKERS COMP ON SATION
NYS11729-9OtherWORKERS COMP ON SATION
NYV9I681Medicare ID - Type Unspecified