Provider Demographics
NPI:1912016189
Name:HENDRICKSON, DIANE C (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 CURVE CREST BLVD W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6070
Mailing Address - Country:US
Mailing Address - Phone:651-439-8283
Mailing Address - Fax:651-439-0576
Practice Address - Street 1:1460 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6070
Practice Address - Country:US
Practice Address - Phone:651-439-8283
Practice Address - Fax:651-439-0576
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1197225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN912S9HEOtherBCBS-MINNESOTA
MNHP47697OtherHEALTHPARTNERS
MN64-05177OtherMEDICA