Provider Demographics
NPI:1982139671
Name:HENDERSON, LYDELL JAMAL
Entity type:Individual
Prefix:MR
First Name:LYDELL
Middle Name:JAMAL
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 1:24333 SOUTHFIELD RD
Mailing Address - Street 2:STE. 212
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2822
Mailing Address - Country:US
Mailing Address - Phone:248-587-7867
Mailing Address - Fax:
Practice Address - Street 1:24333 SOUTHFIELD RD
Practice Address - Street 2:STE. 212
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2822
Practice Address - Country:US
Practice Address - Phone:248-587-7867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver