Provider Demographics
NPI:1174679922
Name:HENNE, KIMBERLY S (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:HENNE
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 1:672 STUART ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1265
Mailing Address - Country:US
Mailing Address - Phone:847-990-5350
Mailing Address - Fax:
Practice Address - Street 1:801 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3204
Practice Address - Country:US
Practice Address - Phone:847-990-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist