Provider Demographics
NPI:1770624231
Name:HENDERSON, DARON GLEN (LMSW)
Entity type:Individual
Prefix:MR
First Name:DARON
Middle Name:GLEN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 NIXON AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5611
Mailing Address - Country:US
Mailing Address - Phone:208-529-4300
Mailing Address - Fax:
Practice Address - Street 1:1285 NIXON AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5611
Practice Address - Country:US
Practice Address - Phone:208-529-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-25799104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker