Provider Demographics
NPI:1912396524
Name:HENDERSON, KAITLIN (ATC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26402
Mailing Address - Street 2:
Mailing Address - City:SILVERTHORNE
Mailing Address - State:CO
Mailing Address - Zip Code:80497-6402
Mailing Address - Country:US
Mailing Address - Phone:989-327-8917
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR STE 180
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5948
Practice Address - Country:US
Practice Address - Phone:970-668-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00017362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty