Provider Demographics
NPI:1851783278
Name:HENDERSON, DERRICK ANTHONY (LMT BOARD CERTIFIED)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:ANTHONY
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LMT BOARD CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6749 NW 62ND PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34482-8443
Mailing Address - Country:US
Mailing Address - Phone:352-817-8823
Mailing Address - Fax:
Practice Address - Street 1:6749 NW 62ND PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34482-8443
Practice Address - Country:US
Practice Address - Phone:352-817-8823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-22
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM 27865225700000X
FLMA 65820225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist