Provider Demographics
NPI:1558484790
Name:HENDERSON, KRISTA ANN (DT)
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61473-9633
Mailing Address - Country:US
Mailing Address - Phone:309-426-2456
Mailing Address - Fax:
Practice Address - Street 1:1220 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-2404
Practice Address - Country:US
Practice Address - Phone:309-734-7902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist