Provider Demographics
NPI:1255447025
Name:HENDERSON, NICHOLE M (PT)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:M
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MARIE
Other - Middle Name:M
Other - Last Name:ZOELLNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1840 ZUMBEHL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-2761
Mailing Address - Country:US
Mailing Address - Phone:636-947-7678
Mailing Address - Fax:636-947-4350
Practice Address - Street 1:1840 ZUMBEHL RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-2761
Practice Address - Country:US
Practice Address - Phone:636-947-7678
Practice Address - Fax:636-947-4350
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005040721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist