Provider Demographics
NPI:1336213776
Name:HENDERSON, ROBERT S
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
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 1:244 WOOD POND RD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-3704
Mailing Address - Country:US
Mailing Address - Phone:860-633-6311
Mailing Address - Fax:
Practice Address - Street 1:16 HIGH ST.
Practice Address - Street 2:
Practice Address - City:SOUTH GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06073
Practice Address - Country:US
Practice Address - Phone:860-659-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000147101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral