Provider Demographics
NPI:1649421272
Name:HENNING, KATIE LYNNE (CMT)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:LYNNE
Last Name:HENNING
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 E MILL ST
Mailing Address - Street 2:BAKER SUITE 106
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-1859
Mailing Address - Country:US
Mailing Address - Phone:920-892-4251
Mailing Address - Fax:
Practice Address - Street 1:411 E MILL ST
Practice Address - Street 2:BAKER SUITE 106
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-1859
Practice Address - Country:US
Practice Address - Phone:920-892-4251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI657-046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist