Provider Demographics
NPI:1053088047
Name:HENDERSON, LISA LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 STRATHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-6282
Mailing Address - Country:US
Mailing Address - Phone:817-917-0040
Mailing Address - Fax:
Practice Address - Street 1:1902 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4602
Practice Address - Country:US
Practice Address - Phone:941-761-1000
Practice Address - Fax:941-761-1009
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31390225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant