Provider Demographics
NPI:1407949290
Name:HENDERSON, SUSAN R (COTA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-2429
Mailing Address - Country:US
Mailing Address - Phone:432-267-3806
Mailing Address - Fax:432-267-3809
Practice Address - Street 1:306 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-2429
Practice Address - Country:US
Practice Address - Phone:432-267-3806
Practice Address - Fax:432-267-3809
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208763224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant