Provider Demographics
NPI:1306188792
Name:HENDERSON, BRETT E
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:E
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12262
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92022-2262
Mailing Address - Country:US
Mailing Address - Phone:619-772-6450
Mailing Address - Fax:
Practice Address - Street 1:5500 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3016
Practice Address - Country:US
Practice Address - Phone:619-588-0098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-23
Last Update Date:2013-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist