Provider Demographics
NPI:1518145903
Name:HENDERSON, RYAN WILLIAMS (PT)
Entity Type:Individual
Prefix:MRS
First Name:RYAN
Middle Name:WILLIAMS
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:RYAN
Other - Middle Name:EDWARDS
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5757
Mailing Address - Fax:601-579-5220
Practice Address - Street 1:103 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-9042
Practice Address - Country:US
Practice Address - Phone:601-268-5757
Practice Address - Fax:601-579-5220
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08188360Medicaid
MS9244128OtherAETNA
MS512I650026Medicare PIN