Provider Demographics
NPI:1174177349
Name:HENDERSON, MAXWELL
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
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 1:4101 NW 22ND ST FL 33993
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-3442
Mailing Address - Country:US
Mailing Address - Phone:239-910-0712
Mailing Address - Fax:855-237-3130
Practice Address - Street 1:730 SW 4TH ST STE 6
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-1984
Practice Address - Country:US
Practice Address - Phone:239-910-0712
Practice Address - Fax:855-237-3130
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-91772106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician