Provider Demographics
NPI:1427658558
Name:HENDERSON, DANIEL THOMAS (MA/CCC-SLP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MA/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 GRAND AVE S APT 5
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5445
Mailing Address - Country:US
Mailing Address - Phone:901-483-2092
Mailing Address - Fax:
Practice Address - Street 1:4701 GRAND AVE S APT 5
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-5445
Practice Address - Country:US
Practice Address - Phone:901-483-2092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty