Provider Demographics
NPI:1700357829
Name:HENDERSON JR, LOVEL (JR)
Entity Type:Individual
Prefix:
First Name:LOVEL
Middle Name:
Last Name:HENDERSON JR
Suffix:
Gender:M
Credentials:JR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 EAST 63RD STREET
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103
Mailing Address - Country:US
Mailing Address - Phone:216-355-8331
Mailing Address - Fax:
Practice Address - Street 1:6600 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103
Practice Address - Country:US
Practice Address - Phone:216-355-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder