Provider Demographics
NPI:1073243119
Name:HENDRICKSON, ALEXANDER R (OT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:R
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:W129N7055 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W129N7055 NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-0538
Practice Address - Country:US
Practice Address - Phone:608-252-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8002-26225X00000X
WI8041-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073243119Medicaid