Healthcare Provider Details

I. General information

NPI: 1275449209
Provider Name (Legal Business Name): NATHAN J HENDRICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PENBROOKE DR BLDG 2
PENFIELD NY
14526-2041
US

IV. Provider business mailing address

19 COUNTY CLARE CRES
FAIRPORT NY
14450-9169
US

V. Phone/Fax

Practice location:
  • Phone: 585-353-0145
  • Fax:
Mailing address:
  • Phone: 585-353-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number018460
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: