Provider Demographics
NPI:1649311929
Name:HENDERSON, SCOTT ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLEN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 COLLEGE ST SE STE F
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-3529
Mailing Address - Country:US
Mailing Address - Phone:360-923-2114
Mailing Address - Fax:360-923-2271
Practice Address - Street 1:3663 COLLEGE ST SE STE F
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-3529
Practice Address - Country:US
Practice Address - Phone:360-923-2114
Practice Address - Fax:360-923-2271
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034380111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAV07531Medicare UPIN
WA8857348Medicare ID - Type Unspecified