Healthcare Provider Details

I. General information

NPI: 1639179849
Provider Name (Legal Business Name): LAWRENCE W HENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date: 06/16/2009
Reactivation Date: 01/04/2010

III. Provider practice location address

1901 WILLOW ST
VINCENNES IN
47591-1034
US

IV. Provider business mailing address

515 BAYOU ST.
VINCENNES IN
47591-1034
US

V. Phone/Fax

Practice location:
  • Phone: 812-885-2720
  • Fax: 812-885-2723
Mailing address:
  • Phone: 812-886-6800
  • Fax: 812-886-6809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01022767A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01022767A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000110659
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM
# 2
Identifier100154500
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: