Healthcare Provider Details

I. General information

NPI: 1639901374
Provider Name (Legal Business Name): MICHAEL HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 W CAMELBACK RD STE 450
PHOENIX AZ
85015-3474
US

IV. Provider business mailing address

7810 N 14TH PL APT 1075
PHOENIX AZ
85020-4340
US

V. Phone/Fax

Practice location:
  • Phone: 602-601-2401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberPTA013915
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: