Individual
MARCELLUS PERRIS HENDERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
725 W TEXAS AVE APT 4031, WASKOM, TX 75692-9516
(318) 861-8938
Mailing address
9403 MANSFIELD RD, SHREVEPORT, LA 71118-3815
(318) 861-8938
(318) 862-3554
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1760852511
PELICAN BAYOU COUNSELING AGENCY
LA
Enumeration date
06/12/2018
Last updated
06/12/2018
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