Healthcare Provider Details

I. General information

NPI: 1780521013
Provider Name (Legal Business Name): ROBERT EVERETT HENDERSON IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 W SAINT CLAIR ST
ROMEO MI
48065-4657
US

IV. Provider business mailing address

294 PROSPECT ST
ROMEO MI
48065-4642
US

V. Phone/Fax

Practice location:
  • Phone: 248-410-1559
  • Fax: 248-419-1856
Mailing address:
  • Phone: 586-623-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: