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General NPI Number Information
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NPI Number | 1235309394
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Entity Type | Individual
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Provider Name | KATHY A. HENDERSON CAC-1
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Gender | Female
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Dates
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Enumeration Date | 03/05/2008
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Last Update Date | 03/05/2008
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Provider Practice Location Address
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Address Line | 19941 GALLAGHER ST.
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City | DETROIT
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State | MI
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Zip | 48234-1655
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Country | US
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Telephone | 313-331-8990
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Fax |
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Provider Business Mailing Address
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Address Line | 19941 GALLAGHER ST
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City | DETROIT
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State | MI
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Zip | 48234-1655
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Country | US
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Telephone | 313-331-8990
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Fax | 313-331-6375
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 1-00030
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License Number State | MI
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