Provider Demographics
NPI:1508164039
Name:HENINGER, LYNAE MARIE (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:LYNAE
Middle Name:MARIE
Last Name:HENINGER
Suffix:
Gender:F
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 W MCMILLAN RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6291
Mailing Address - Country:US
Mailing Address - Phone:208-887-8684
Mailing Address - Fax:208-887-9226
Practice Address - Street 1:3035 W MCMILLAN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6291
Practice Address - Country:US
Practice Address - Phone:208-887-8684
Practice Address - Fax:208-887-9226
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist