Provider Demographics
NPI:1982652426
Name:HENDERSON, THOMAS (PHD, HSPP, LMFT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHD, HSPP, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-6826
Mailing Address - Country:US
Mailing Address - Phone:812-448-1151
Mailing Address - Fax:
Practice Address - Street 1:221 E WESLEY DR
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-6826
Practice Address - Country:US
Practice Address - Phone:812-448-1151
Practice Address - Fax:812-446-5302
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20090131103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100079240Medicaid