Provider Demographics
NPI:1275101982
Name:HENNING, MADISON ISABELLA (PT,DPT)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ISABELLA
Last Name:HENNING
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 FUNNYCIDE DR
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-7705
Mailing Address - Country:US
Mailing Address - Phone:406-579-9920
Mailing Address - Fax:
Practice Address - Street 1:307 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NY
Practice Address - Zip Code:13624-1022
Practice Address - Country:US
Practice Address - Phone:315-686-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046501-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist