Provider Demographics
NPI:1720382120
Name:HENDERSON, DWIGHT E (MA-SLP, TSSLD, NYSC)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:E
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MA-SLP, TSSLD, NYSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 LINCOLN RD APT B23
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4057
Mailing Address - Country:US
Mailing Address - Phone:917-513-5796
Mailing Address - Fax:
Practice Address - Street 1:57 LINCOLN RD APT B23
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-4057
Practice Address - Country:US
Practice Address - Phone:917-513-5796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019778-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist