Provider Demographics
NPI:1851989354
Name:HENDERSON, MODESTY N
Entity Type:Individual
Prefix:
First Name:MODESTY
Middle Name:N
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12707 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-4751
Mailing Address - Country:US
Mailing Address - Phone:216-278-5652
Mailing Address - Fax:
Practice Address - Street 1:12707 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-4751
Practice Address - Country:US
Practice Address - Phone:216-278-5652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health