Provider Demographics
NPI:1386128205
Name:HENDERSON, THERESA E (CPRP, CRPS)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CPRP, CRPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2257 SANDY CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5235
Mailing Address - Country:US
Mailing Address - Phone:904-314-2060
Mailing Address - Fax:
Practice Address - Street 1:2257 SANDY CT
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5235
Practice Address - Country:US
Practice Address - Phone:904-314-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12768OtherFLORIDA BOARD OF CERTIFICATION