Provider Demographics
NPI:1326152778
Name:HENDRICKSON, WADE LARS (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:LARS
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 E CATCLAW ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3376
Mailing Address - Country:US
Mailing Address - Phone:480-735-9234
Mailing Address - Fax:480-626-4217
Practice Address - Street 1:2107 E CATCLAW ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3376
Practice Address - Country:US
Practice Address - Phone:480-735-9234
Practice Address - Fax:480-626-4217
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHAD2033237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist