Provider Demographics
NPI:1679873459
Name:HENDERSON, GREGORY JOSEPH (LAC MAC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JOSEPH
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LAC MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19403-3105
Mailing Address - Country:US
Mailing Address - Phone:610-539-5600
Mailing Address - Fax:
Practice Address - Street 1:1 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403-3105
Practice Address - Country:US
Practice Address - Phone:610-539-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK000982171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist