1871124768 NPI number — MR. ANDREW TODD HENDERSON LPC

Table of content: MR. ANDREW TODD HENDERSON LPC (NPI 1871124768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871124768 NPI number — MR. ANDREW TODD HENDERSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
ANDREW
Provider Middle Name:
TODD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1871124768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21555 PARKWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48167-9064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-756-3815
Provider Business Mailing Address Fax Number:
248-476-7403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 DETROIT METRO AIRPORT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48242-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-247-5205
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2020

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: 101YP2500X , with the licence number:  4764124 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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