Healthcare Provider Details

I. General information

NPI: 1174177349
Provider Name (Legal Business Name): MAXWELL HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 SW 4TH ST STE 6
CAPE CORAL FL
33991-1984
US

IV. Provider business mailing address

4101 NW 22ND ST FL 33993
CAPE CORAL FL
33993-3442
US

V. Phone/Fax

Practice location:
  • Phone: 239-910-0712
  • Fax: 855-237-3130
Mailing address:
  • Phone: 239-910-0712
  • Fax: 855-237-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-91772
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: