Provider Demographics
NPI:1851703649
Name:HENDERSON, TRISTA (DPT)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:HENDERSON
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 1:11305 LEAVENWORTH RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109
Mailing Address - Country:US
Mailing Address - Phone:816-226-0505
Mailing Address - Fax:
Practice Address - Street 1:11305 LEAVENWORTH RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-3420
Practice Address - Country:US
Practice Address - Phone:816-226-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03932225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist