Basic Information
| Provider Information | |||||||||
| NPI: | 1427658558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MA/CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1917 OAKHAMPTON PL | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014832092 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2175 ROSALINE AVE | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960012549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302256000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2020 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 29643 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.