Basic Information
| Provider Information | |||||||||
| NPI: | 1003247958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284466 | ||||||||
| FaxNumber: | 8027284197 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 FOGG FARM ROAD | ||||||||
| Address2: | |||||||||
| City: | WILDER | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022951311 | ||||||||
| FaxNumber: | 8022951312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2013 | ||||||||
| LastUpdateDate: | 12/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 00608 | VT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.