Provider Demographics
NPI:1073133385
Name:HENDRICK, DUSTIN BLAKE (DPT)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:BLAKE
Last Name:HENDRICK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 READING AVE APT 412
Mailing Address - Street 2:
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1284
Mailing Address - Country:US
Mailing Address - Phone:434-774-6720
Mailing Address - Fax:
Practice Address - Street 1:590 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-9195
Practice Address - Country:US
Practice Address - Phone:717-274-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0281902251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT028190OtherPHYSICAL THERAPIST STATE LICENSE