Provider Demographics
NPI:1396047080
Name:HENDERSON, DAVEY
Entity type:Individual
Prefix:
First Name:DAVEY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12641 E. EARLL DRIVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392
Mailing Address - Country:US
Mailing Address - Phone:602-316-9834
Mailing Address - Fax:
Practice Address - Street 1:12641 E. EARLL DRIVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392
Practice Address - Country:US
Practice Address - Phone:602-316-9834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1230257385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child