Provider Demographics
NPI:1386813376
Name:HENDERSHOT, JOHN (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HENDERSHOT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14502 N DALE MABRY HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2040
Mailing Address - Country:US
Mailing Address - Phone:813-265-4811
Mailing Address - Fax:
Practice Address - Street 1:14502 N DALE MABRY HWY STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2040
Practice Address - Country:US
Practice Address - Phone:813-265-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73631Medicare UPIN