Provider Demographics
NPI:1417628751
Name:HENDERSON, DALLAS (BA)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5754 CALAIS LN
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-2089
Mailing Address - Country:US
Mailing Address - Phone:256-458-8544
Mailing Address - Fax:
Practice Address - Street 1:2814 W DR MARTIN LUTHER KING JR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6374
Practice Address - Country:US
Practice Address - Phone:813-520-2807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health