Provider Demographics
NPI:1952435711
Name:HENDERSON, GARY LYNN (MFT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:LYNN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 SUNRISE AVE
Mailing Address - Street 2:#D115
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4516
Mailing Address - Country:US
Mailing Address - Phone:915-201-7348
Mailing Address - Fax:916-772-3627
Practice Address - Street 1:720 SUNRISE AVE
Practice Address - Street 2:#D115
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4516
Practice Address - Country:US
Practice Address - Phone:915-201-7348
Practice Address - Fax:916-772-3627
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC7053106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist