Provider Demographics
NPI:1659463354
Name:HENDERSON, MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14463 THELMA CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8460
Mailing Address - Country:US
Mailing Address - Phone:574-271-1065
Mailing Address - Fax:
Practice Address - Street 1:1005 N HICKORY RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3723
Practice Address - Country:US
Practice Address - Phone:574-233-5754
Practice Address - Fax:574-233-7406
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008295A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000356942OtherANTHEM