Provider Demographics
NPI:1043811102
Name:HENDRICKS, KRISJA (LCAT, R-DMT)
Entity Type:Individual
Prefix:
First Name:KRISJA
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:LCAT, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:978 METROPOLITAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-2635
Mailing Address - Country:US
Mailing Address - Phone:443-655-8139
Mailing Address - Fax:
Practice Address - Street 1:978 METROPOLITAN AVE APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-2635
Practice Address - Country:US
Practice Address - Phone:443-655-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002438-01225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist