Provider Demographics
NPI:1023365277
Name:HENDRICKSON, MARY ELLEN (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4705
Mailing Address - Country:US
Mailing Address - Phone:406-788-2214
Mailing Address - Fax:406-727-1324
Practice Address - Street 1:1623 13TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4705
Practice Address - Country:US
Practice Address - Phone:406-788-2214
Practice Address - Fax:406-727-1324
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist