Provider Demographics
NPI:1336763358
Name:HENDERSON, BURGANDY D
Entity Type:Individual
Prefix:
First Name:BURGANDY
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 E CONRON AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1805
Mailing Address - Country:US
Mailing Address - Phone:217-737-4331
Mailing Address - Fax:
Practice Address - Street 1:14792 CATLIN TILTON RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61834-5116
Practice Address - Country:US
Practice Address - Phone:217-443-6430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.014592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.014592OtherSTATE LICENSE