Provider Demographics
NPI:1043501117
Name:HENDERSON, PATRICE L (MS)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 E 114TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4921
Mailing Address - Country:US
Mailing Address - Phone:773-660-4630
Mailing Address - Fax:773-660-4650
Practice Address - Street 1:33 E 114TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4921
Practice Address - Country:US
Practice Address - Phone:773-660-4630
Practice Address - Fax:773-660-4650
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00105739225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor