Provider Demographics
NPI:1073557070
Name:HENDERSON, ROGER (PT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 CHENEY HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6702
Mailing Address - Country:US
Mailing Address - Phone:321-745-7106
Mailing Address - Fax:321-267-0611
Practice Address - Street 1:1954 ROCKLEDGE BLVD STE 119
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3761
Practice Address - Country:US
Practice Address - Phone:321-433-1500
Practice Address - Fax:321-433-1556
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19703208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY043LOtherBCBS OF FLORIDA
FLY043LOtherBCBS OF FLORIDA