Provider Demographics
NPI:1811149099
Name:HENDERSON, REGINALD QUENTINE SR (CSAC-I)
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:QUENTINE
Last Name:HENDERSON
Suffix:SR
Gender:M
Credentials:CSAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 BIVINS ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-1523
Mailing Address - Country:US
Mailing Address - Phone:919-224-9458
Mailing Address - Fax:
Practice Address - Street 1:3622 LYCKAN PKWY STE 6008
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2570
Practice Address - Country:US
Practice Address - Phone:919-381-6816
Practice Address - Fax:919-381-6818
Is Sole Proprietor?:No
Enumeration Date:2008-10-19
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health