Provider Demographics
NPI:1275725285
Name:HENDERSON, ALICIA (ATC, OTC)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 PEACHTREE RD NE
Mailing Address - Street 2:STE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1414
Mailing Address - Country:US
Mailing Address - Phone:404-355-0743
Mailing Address - Fax:
Practice Address - Street 1:2045 PEACHTREE RD NE
Practice Address - Street 2:STE 700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1414
Practice Address - Country:US
Practice Address - Phone:404-355-0743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246ZS0410X
GAAT0014292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer