Provider Demographics
NPI:1770502817
Name:HENRIKSSON, KENNETH I (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:I
Last Name:HENRIKSSON
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 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:605-242-0020
Practice Address - Street 1:3430 GRAND AVE
Practice Address - Street 2:#400
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3741
Practice Address - Country:US
Practice Address - Phone:847-782-9860
Practice Address - Fax:847-782-9866
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-009319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist