Provider Demographics
NPI:1699854166
Name:HENDERSON, CARLTON KEITH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CARLTON
Middle Name:KEITH
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1384 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2327
Mailing Address - Country:US
Mailing Address - Phone:901-493-1103
Mailing Address - Fax:901-726-4281
Practice Address - Street 1:1384 MADISON AVENUE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-493-1103
Practice Address - Fax:901-726-4281
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN-048101YA0400X
AR1939-C1041C0700X
TN36611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y488Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER