Provider Demographics
NPI:1265473508
Name:HENNEKE, KERRY (PT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:HENNEKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 LILAC LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-2625
Mailing Address - Country:US
Mailing Address - Phone:361-572-0385
Mailing Address - Fax:361-572-0382
Practice Address - Street 1:4504 LILAC LN
Practice Address - Street 2:SUITE 1
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2625
Practice Address - Country:US
Practice Address - Phone:361-572-0385
Practice Address - Fax:361-572-0382
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1103943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282708104Medicaid
TX282708103Medicaid