Provider Demographics
NPI:1932402062
Name:HENDERSON, CARLOS (RN)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15910 MIDLAND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2425
Mailing Address - Country:US
Mailing Address - Phone:216-249-4038
Mailing Address - Fax:
Practice Address - Street 1:15910 MIDLAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2425
Practice Address - Country:US
Practice Address - Phone:216-249-4038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-12
Last Update Date:2010-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.359480163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health