Provider Demographics
NPI:1972779379
Name:HENDERSON, CHARLES (LMSW-AP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LMSW-AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17319 GARWOOD CHASE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5839
Mailing Address - Country:US
Mailing Address - Phone:210-872-4302
Mailing Address - Fax:
Practice Address - Street 1:17319 GARWOOD CHASE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-5839
Practice Address - Country:US
Practice Address - Phone:210-872-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12720101Y00000X
TX99326164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No164X00000XNursing Service ProvidersLicensed Vocational Nurse