Provider Demographics
NPI:1386108066
Name:HENDERSON, JOHN (CDCA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 S TECUMSEH RD LOT 118
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-8587
Mailing Address - Country:US
Mailing Address - Phone:937-340-1141
Mailing Address - Fax:
Practice Address - Street 1:323 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-4934
Practice Address - Country:US
Practice Address - Phone:937-318-8103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.167280101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)