Provider Demographics
NPI:1790931616
Name:HENRICKSEN, KELLI ANN (DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:HENRICKSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 LILLY RD NE STE 250
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5101
Mailing Address - Country:US
Mailing Address - Phone:360-486-6777
Mailing Address - Fax:360-459-9954
Practice Address - Street 1:525 LILLY RD NE STE 250
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-486-6777
Practice Address - Fax:360-459-9954
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60028377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist