Provider Demographics
NPI:1336195494
Name:HENDERSON, AMANDA CATHERINE (PT)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:CATHERINE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:CATHERINE
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2217 DECATUR HWY
Mailing Address - Street 2:SUITE 123
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-2301
Mailing Address - Country:US
Mailing Address - Phone:205-418-1200
Mailing Address - Fax:205-418-1210
Practice Address - Street 1:2217 DECATUR HWY
Practice Address - Street 2:SUITE 123
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2301
Practice Address - Country:US
Practice Address - Phone:205-418-1200
Practice Address - Fax:205-418-1210
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009967425Medicaid
AL6410036OtherUNITED HEALTHCARE
ALQ24657Medicare UPIN
AL009967425Medicaid