Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003214339 |
---|---|
Provider Name | Mr. Scott Henderson |
First Address | St Augustine, FL 32095-9631 |
Second Address | Daytona Beach, FL 32114-1316 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2014 |
Last Update Date | 18/12/2014 |