Provider Demographics
NPI:1851332621
Name:HENDRICKS, DANIEL E (PHD, ADC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:PHD, ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 INTERLACHEN DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9528
Mailing Address - Country:US
Mailing Address - Phone:706-481-8181
Mailing Address - Fax:
Practice Address - Street 1:1287 MARKS CHURCH RD
Practice Address - Street 2:SUITE F
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6330
Practice Address - Country:US
Practice Address - Phone:706-481-8181
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA203101YA0400X
GA973103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA973OtherPSYCHOLOGY LICENSE
GA00472821BMedicaid
GA00472821BMedicaid
GAR81853Medicare UPIN