Provider Demographics
NPI:1811707102
Name:HENDERSON, MATTHEW LEE
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:ANGELUS OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:92305-0124
Mailing Address - Country:US
Mailing Address - Phone:951-442-3306
Mailing Address - Fax:
Practice Address - Street 1:1908 BUSINESS CENTER DR STE 220
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3468
Practice Address - Country:US
Practice Address - Phone:909-890-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT152091106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty