Provider Demographics
NPI:1053453720
Name:HENDERSON, CRYSTAL (PT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W BRUCE ST STE B
Mailing Address - Street 2:PO BOX 1192
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2319
Mailing Address - Country:US
Mailing Address - Phone:812-522-7887
Mailing Address - Fax:812-522-7326
Practice Address - Street 1:930 BARACHEL LN STE 400
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-3253
Practice Address - Country:US
Practice Address - Phone:812-663-5072
Practice Address - Fax:812-662-6619
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004775A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000329061OtherINDIVIDUAL BCBS NUMBER
IN100140690Medicaid
IN100140690Medicaid