Provider Demographics
NPI:1205269768
Name:HENSON, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:HENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 WENTZVILLE PKWY
Mailing Address - Street 2:SUITE 123
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3476
Mailing Address - Country:US
Mailing Address - Phone:636-332-1313
Mailing Address - Fax:
Practice Address - Street 1:1155 WENTZVILLE PKWY
Practice Address - Street 2:SUITE 123
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3476
Practice Address - Country:US
Practice Address - Phone:636-332-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist