Provider Demographics
NPI:1265665053
Name:HENNEBERGER, KATHLEEN LYNN (DC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LYNN
Last Name:HENNEBERGER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:LYNN
Other - Last Name:OVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:369 DELAWARE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202
Mailing Address - Country:US
Mailing Address - Phone:716-854-1563
Mailing Address - Fax:716-854-1567
Practice Address - Street 1:196 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-2010
Practice Address - Country:US
Practice Address - Phone:716-400-9462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY70011732111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor