Provider Demographics
NPI:1679873855
Name:HENDERSON, LISA A
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SE ADAMS RD
Mailing Address - Street 2:A-100
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-8437
Mailing Address - Country:US
Mailing Address - Phone:918-331-9922
Mailing Address - Fax:918-331-9971
Practice Address - Street 1:4100 SE ADAMS RD
Practice Address - Street 2:A-100
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-8437
Practice Address - Country:US
Practice Address - Phone:918-331-9922
Practice Address - Fax:918-331-9971
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist