Provider Demographics
NPI:1356361422
Name:HENDERSON, HAROLD LENARD (ATC/LAT)
Entity type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:LENARD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 OAK BLVD
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-9223
Mailing Address - Country:US
Mailing Address - Phone:352-748-4655
Mailing Address - Fax:407-935-4609
Practice Address - Street 1:93 PANTHER PAWS TRL
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4407
Practice Address - Country:US
Practice Address - Phone:407-935-3600
Practice Address - Fax:407-935-3609
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 15972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer