Provider Demographics
NPI:1104834670
Name:HENSLEY, RENEE L (PT)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:L
Last Name:HENSLEY
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 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:411 E IRELAND RD
Practice Address - Street 2:STE 400
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2680
Practice Address - Country:US
Practice Address - Phone:574-231-8950
Practice Address - Fax:574-231-8955
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003014A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN218470Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER