MEDICARE: DR. DANIEL J HENDERSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY0003688	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	75919	OTHER	FL	BCBS OF FLORIDA

General Provider Information

NPI Number	:	1720096340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL J HENDERSON PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 2854
Second Line	:
City	:	OCALA
State	:	FL
Zip	:	34478-2854
Country	:	US
Telephone Number	:	352-732-3333
Fax Number	:	352-732-2469

Provider Business Practice Location Address
First Line	:	1515 E SILVER SPRINGS BLVD
Second Line	:	SUITE 112
City	:	OCALA
State	:	FL
Zip	:	34470-6831
Country	:	US
Telephone Number	:	352-732-3333
Fax Number	:	352-732-2469

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/08/2007

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