Provider Demographics
NPI:1801019302
Name:HENDERSON, LARRY P (DMIN)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:P
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 845
Mailing Address - Street 2:
Mailing Address - City:MAYFLOWER
Mailing Address - State:AR
Mailing Address - Zip Code:72106-0845
Mailing Address - Country:US
Mailing Address - Phone:501-328-5525
Mailing Address - Fax:
Practice Address - Street 1:1100 BOB COURTWAY DR
Practice Address - Street 2:SUITE 9
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4766
Practice Address - Country:US
Practice Address - Phone:501-328-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP9005009101YP1600X, 101YP2500X
ARM9712037106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist