Provider Demographics
NPI:1982407839
Name:HENDERSON, KELBY UNIQUE
Entity type:Individual
Prefix:
First Name:KELBY
Middle Name:UNIQUE
Last Name:HENDERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-6338
Mailing Address - Country:US
Mailing Address - Phone:510-213-9162
Mailing Address - Fax:
Practice Address - Street 1:103 GLENN ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-6338
Practice Address - Country:US
Practice Address - Phone:510-213-9162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician