Provider Demographics
NPI:1396794871
Name:HENDERSON, ALEXANDER DAVIS (PHD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DAVIS
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MATHIS FERRY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-2979
Mailing Address - Country:US
Mailing Address - Phone:843-971-5171
Mailing Address - Fax:
Practice Address - Street 1:250 MATHIS FERRY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-2979
Practice Address - Country:US
Practice Address - Phone:843-971-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC984103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0406Medicaid