Provider Demographics
NPI:1225097942
Name:HENNEBERRY, CRAIG MICHAEL (BS, PT, DPT)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:MICHAEL
Last Name:HENNEBERRY
Suffix:
Gender:M
Credentials:BS, PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 E 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-4908
Mailing Address - Country:US
Mailing Address - Phone:509-456-6917
Mailing Address - Fax:509-456-5902
Practice Address - Street 1:2507 E 27TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4908
Practice Address - Country:US
Practice Address - Phone:509-456-6917
Practice Address - Fax:509-456-5902
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA185842OtherLABOR & INDUSTRIES
WA8405334Medicaid
WA8405334Medicaid