Provider Demographics
NPI:1659033421
Name:HENDERSON, TOMMY RAY
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:RAY
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 1:2227 S GARNETT RD STE 109
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-5115
Mailing Address - Country:US
Mailing Address - Phone:918-470-9605
Mailing Address - Fax:
Practice Address - Street 1:2227 S GARNETT RD STE 109
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5115
Practice Address - Country:US
Practice Address - Phone:918-470-9605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling