Provider Demographics
NPI:1568765402
Name:HENDERSON, KRISTA (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 NW 179TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4009
Mailing Address - Country:US
Mailing Address - Phone:405-201-2174
Mailing Address - Fax:
Practice Address - Street 1:6525 N MERIDIAN AVE STE 311
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1410
Practice Address - Country:US
Practice Address - Phone:405-721-1115
Practice Address - Fax:405-721-2025
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2623235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist