Doctor Name: | GREGORY HENDERSON |
NPI Number: | 1003247958 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LADC |
License Number: | 00608 |
Business Practice Address: | 39 Fogg Farm Road Wilder, VT - 05088 |
Business Phone Number: | 8022951311 |
Business Fax Number: | 8022951312 |
Mailing Address: | 11 N Main St, RANDOLPH |
State: | VT |
Postal Code: | 050601126 |
Phone Number: | 8027284466 |
Fax Number: | 8027284197 |
NPI Enumeration Date: | 12/03/2013 |
NPI Last Update Date: | 12/03/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YA0400X |
License Number: | 00608 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | VT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |