Provider Demographics
NPI:1790932895
Name:HENDERSON, ANDREA DIANE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:DIANE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S IRENA AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4355
Mailing Address - Country:US
Mailing Address - Phone:310-977-5518
Mailing Address - Fax:310-540-9512
Practice Address - Street 1:640 S IRENA AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-4355
Practice Address - Country:US
Practice Address - Phone:310-977-5518
Practice Address - Fax:310-540-9512
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist