Provider Demographics
NPI:1386457505
Name:HENDERSON, TRENT L
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 SAUSSY RD UNIT 401
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-1120
Mailing Address - Country:US
Mailing Address - Phone:704-691-5031
Mailing Address - Fax:
Practice Address - Street 1:1535 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3315
Practice Address - Country:US
Practice Address - Phone:615-560-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician