Provider Demographics
NPI:1730102484
Name:HENDERSON, ROY EDWARD (MA)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:EDWARD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7844 MADISON AVENUE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3595
Mailing Address - Country:US
Mailing Address - Phone:916-962-7101
Mailing Address - Fax:916-962-7102
Practice Address - Street 1:7844 MADISON AVENUE
Practice Address - Street 2:SUITE 105
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3595
Practice Address - Country:US
Practice Address - Phone:916-962-7101
Practice Address - Fax:916-962-7102
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27845106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist