Provider Demographics
NPI:1790552727
Name:HENDERSON, DAVID EDWARD (LMT, CNMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LMT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 JET WING CIR W
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-2143
Mailing Address - Country:US
Mailing Address - Phone:719-244-2229
Mailing Address - Fax:
Practice Address - Street 1:4510 JET WING CIR W
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-2143
Practice Address - Country:US
Practice Address - Phone:719-244-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0022178225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist