1336102631 NPI number — MRS. KRISTEN LEIGH HENDERSON DPT

Table of content: MRS. KRISTEN LEIGH HENDERSON DPT (NPI 1336102631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336102631 NPI number — MRS. KRISTEN LEIGH HENDERSON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
KRISTEN
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEEKS
Provider Other First Name:
KRISTEN
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336102631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 N ADAMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32351-2404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-875-0333
Provider Business Mailing Address Fax Number:
850-875-0335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 N ADAMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32351-2404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-875-0333
Provider Business Practice Location Address Fax Number:
85-875-0335
Provider Enumeration Date:
04/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  PTA19458 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT33163 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PT33163 . This is a "PHYSICAL THERAPY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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