Provider Demographics
NPI:1356466361
Name:HENRICKSON, LARRY KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:KEITH
Last Name:HENRICKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2859
Mailing Address - Country:US
Mailing Address - Phone:318-251-9231
Mailing Address - Fax:
Practice Address - Street 1:LA TECH UNIVERSITY SPEECH HEARING CTR
Practice Address - Street 2:ROBINSON HALL - ROOM 218
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71272-0001
Practice Address - Country:US
Practice Address - Phone:318-257-4764
Practice Address - Fax:318-257-4492
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5708231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist