Provider Demographics
NPI:1821805623
Name:HENDERSON, MAURICE
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:
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 1:5895 WALSH PT APT 205
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2043
Mailing Address - Country:US
Mailing Address - Phone:719-370-2886
Mailing Address - Fax:
Practice Address - Street 1:1880 OFFICE CLUB PT STE 301
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-5020
Practice Address - Country:US
Practice Address - Phone:719-212-1336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0026079225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist