Provider Demographics
NPI:1427842889
Name:HENDERSON, LARRY DEAN JR
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:HENDERSON
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 BUCKSKIN LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-1423
Mailing Address - Country:US
Mailing Address - Phone:312-383-3786
Mailing Address - Fax:
Practice Address - Street 1:3610 BUCKSKIN LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-1423
Practice Address - Country:US
Practice Address - Phone:312-383-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician