Basic Information
| Provider Information | |||||||||
| NPI: | 1497337570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDERSON BEHAVIORAL HEALTH, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548812386 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 SW 27TH AVE | ||||||||
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| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333122051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544973856 | ||||||||
| FaxNumber: | 9544972901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2021 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | LOMAN | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9544973856 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HENDERSON BEHAVIORAL HEALTH, INC. | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 060338400 | 05 | FL | MEDICAID |