Provider Demographics
NPI:1235452186
Name:HENDERSON, JOHN WILLIAM (ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:HENDERSON
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 1:7473 SHAY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84405-9202
Mailing Address - Country:US
Mailing Address - Phone:801-475-7508
Mailing Address - Fax:
Practice Address - Street 1:7473 SHAY LN
Practice Address - Street 2:
Practice Address - City:SOUTH WEBER
Practice Address - State:UT
Practice Address - Zip Code:84405-9202
Practice Address - Country:US
Practice Address - Phone:801-475-7508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-07
Last Update Date:2010-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6952002-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer