Provider Demographics
NPI:1932840956
Name:HENDERSON, PEYTON MARIE
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:MARIE
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 1:166 GRAY ST
Mailing Address - Street 2:
Mailing Address - City:TRION
Mailing Address - State:GA
Mailing Address - Zip Code:30753-1402
Mailing Address - Country:US
Mailing Address - Phone:706-936-1356
Mailing Address - Fax:
Practice Address - Street 1:805 MADISON ST SE STE 2E
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4424
Practice Address - Country:US
Practice Address - Phone:256-755-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALBACB709777106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician