Provider Demographics
NPI:1114341997
Name:HERNDON, KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HERNDON
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 1:1313 AUBURN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-2449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 N COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-1103
Practice Address - Country:US
Practice Address - Phone:636-629-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist