Provider Demographics
NPI:1285308767
Name:HENDERSON, THOMAS EDWARD (MA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 ROCKY BROOK CT
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5230
Mailing Address - Country:US
Mailing Address - Phone:407-584-7179
Mailing Address - Fax:
Practice Address - Street 1:1964 HOWELL BRANCH RD STE 106
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-1042
Practice Address - Country:US
Practice Address - Phone:407-657-5800
Practice Address - Fax:407-657-4249
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23551101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health