Healthcare Provider Details

I. General information

NPI: 1811349962
Provider Name (Legal Business Name): BETTINA HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MEAD ST
ROCHESTER NY
14621-4511
US

IV. Provider business mailing address

51 MEAD ST
ROCHESTER NY
14621-4511
US

V. Phone/Fax

Practice location:
  • Phone: 585-498-5287
  • Fax:
Mailing address:
  • Phone: 585-498-5287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number611489217
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: