Provider Demographics
NPI:1396040077
Name:HENDERSON, SHELLY MARIE (RMA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5021 E CARGILL LN
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-9142
Mailing Address - Country:US
Mailing Address - Phone:509-238-4171
Mailing Address - Fax:
Practice Address - Street 1:5612 E CARGILL LN
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:WA
Practice Address - Zip Code:99005-9110
Practice Address - Country:US
Practice Address - Phone:509-238-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA249694320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities