Provider Demographics
NPI:1265925424
Name:HENDERSON, MARCELLUS PERRIS
Entity type:Individual
Prefix:
First Name:MARCELLUS
Middle Name:PERRIS
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 1:9403 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3815
Mailing Address - Country:US
Mailing Address - Phone:318-861-8938
Mailing Address - Fax:318-862-3554
Practice Address - Street 1:725 W TEXAS AVE APT 4031
Practice Address - Street 2:
Practice Address - City:WASKOM
Practice Address - State:TX
Practice Address - Zip Code:75692-9516
Practice Address - Country:US
Practice Address - Phone:318-861-8938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1760852511OtherPELICAN BAYOU COUNSELING AGENCY