Provider Demographics
NPI:1295342848
Name:HENDERSON, BLAKE RUSSELL
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:RUSSELL
Last Name:HENDERSON
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 1:4407 NE 45TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64117-1823
Mailing Address - Country:US
Mailing Address - Phone:816-745-6270
Mailing Address - Fax:
Practice Address - Street 1:515 W 75TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-1512
Practice Address - Country:US
Practice Address - Phone:816-745-6270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist