Provider Demographics
NPI:1265134969
Name:HENDERSON, RAY DAVID (PTA)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:DAVID
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 OAK MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98568-9750
Mailing Address - Country:US
Mailing Address - Phone:360-591-9766
Mailing Address - Fax:
Practice Address - Street 1:1006 N H ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2521
Practice Address - Country:US
Practice Address - Phone:360-537-6032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60932735225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant