Provider Demographics
NPI:1164096962
Name:HENNEBERG, DOUGLAS R (ATC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:HENNEBERG
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E HENRIETTA RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-5701
Mailing Address - Country:US
Mailing Address - Phone:585-292-2848
Mailing Address - Fax:
Practice Address - Street 1:1000 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-5701
Practice Address - Country:US
Practice Address - Phone:585-292-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0010922081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine