Provider Demographics
NPI:1952333080
Name:HENDERSON, CARL
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 802
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5202
Mailing Address - Country:US
Mailing Address - Phone:901-763-0037
Mailing Address - Fax:901-763-0065
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 802
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-763-0037
Practice Address - Fax:901-763-0065
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT4300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3659619Medicare ID - Type Unspecified