Provider Demographics
NPI:1639040397
Name:HENDERSON, KENNETH RAY
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAY
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 1:13115 WHITTINGTON DR APT 9310
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-2690
Mailing Address - Country:US
Mailing Address - Phone:804-335-7549
Mailing Address - Fax:
Practice Address - Street 1:13115 WHITTINGTON DR APT 9310
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-2690
Practice Address - Country:US
Practice Address - Phone:804-335-7549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QM0850X, 101YM0800X, 261QM0855X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health