Provider Demographics
NPI:1831132778
Name:HENDERSON, JUDITH BLAIR (PHD)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:BLAIR
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 OLSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 4002
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5149
Mailing Address - Country:US
Mailing Address - Phone:763-595-7294
Mailing Address - Fax:763-595-7293
Practice Address - Street 1:5101 OLSON MEMORIAL HWY
Practice Address - Street 2:SUITE 4002
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-5149
Practice Address - Country:US
Practice Address - Phone:763-595-7294
Practice Address - Fax:763-595-7293
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3720103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service