Provider Demographics
NPI:1205916004
Name:HENDERSON, HALLIE (OD)
Entity type:Individual
Prefix:DR
First Name:HALLIE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 MOODY RD
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-8778
Mailing Address - Country:US
Mailing Address - Phone:601-947-3250
Mailing Address - Fax:
Practice Address - Street 1:7855 MOFFETT RD
Practice Address - Street 2:
Practice Address - City:SEMMES
Practice Address - State:AL
Practice Address - Zip Code:36575-5411
Practice Address - Country:US
Practice Address - Phone:251-649-7752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR-149 TA-684152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist