Provider Demographics
NPI:1902673668
Name:HENDERSON, DERRICK L
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 LONG PINES DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-3412
Mailing Address - Country:US
Mailing Address - Phone:318-572-6337
Mailing Address - Fax:
Practice Address - Street 1:3005 LONG PINES DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-3412
Practice Address - Country:US
Practice Address - Phone:318-572-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker