Provider Demographics
NPI:1912152117
Name:GILBERT-HENDERSON, MARY L (PHD, LD/N)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:GILBERT-HENDERSON
Suffix:
Gender:F
Credentials:PHD, LD/N
Other - Prefix:DR
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:GILBERT-HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LD/N
Mailing Address - Street 1:1401 CLAUDE PICHARD DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5138
Mailing Address - Country:US
Mailing Address - Phone:850-566-2121
Mailing Address - Fax:850-878-2978
Practice Address - Street 1:2024 PT MILLIGAN RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32352-5012
Practice Address - Country:US
Practice Address - Phone:850-566-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2623133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist