MEDICARE: KATHY A. HENDERSON CAC-1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	1-00030	MI

General Provider Information

NPI Number	:	1235309394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY A. HENDERSON CAC-1

Provider Business Mailing Address
First Line	:	19941 GALLAGHER ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-1655
Country	:	US
Telephone Number	:	313-331-8990
Fax Number	:	313-331-6375

Provider Business Practice Location Address
First Line	:	19941 GALLAGHER ST.
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-1655
Country	:	US
Telephone Number	:	313-331-8990
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2008
Last Update Date	:	03/05/2008

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