Provider Demographics
NPI:1013059864
Name:HENDERSON, STACEY ANN (MSPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-2269
Mailing Address - Country:US
Mailing Address - Phone:856-663-2840
Mailing Address - Fax:
Practice Address - Street 1:5105 N PARK DR
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-4630
Practice Address - Country:US
Practice Address - Phone:856-665-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT011562L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist