1265925424 NPI number — MARCELLUS PERRIS HENDERSON

Table of content: MARCELLUS PERRIS HENDERSON (NPI 1265925424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265925424 NPI number — MARCELLUS PERRIS HENDERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
MARCELLUS
Provider Middle Name:
PERRIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265925424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9403 MANSFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71118-3815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-861-8938
Provider Business Mailing Address Fax Number:
318-862-3554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 W TEXAS AVE APT 4031
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASKOM
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75692-9516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-861-8938
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1760852511 . This is a "PELICAN BAYOU COUNSELING AGENCY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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