Provider Demographics
NPI:1780432500
Name:HENDERSON, GRACELET C
Entity type:Individual
Prefix:
First Name:GRACELET
Middle Name:C
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17245 E CENTER PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80017-2213
Mailing Address - Country:US
Mailing Address - Phone:805-270-9744
Mailing Address - Fax:
Practice Address - Street 1:17245 E CENTER PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80017-2213
Practice Address - Country:US
Practice Address - Phone:805-270-9744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician