Provider Demographics
NPI:1356375224
Name:HENDERSHOTT, TRACY LYNN (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:HENDERSHOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 4TH PLACE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033
Mailing Address - Country:US
Mailing Address - Phone:425-576-1046
Mailing Address - Fax:
Practice Address - Street 1:17330 135TH AVE NE
Practice Address - Street 2:SUITE 1C
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072
Practice Address - Country:US
Practice Address - Phone:425-481-0236
Practice Address - Fax:425-481-8266
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
911400843OtherBLUE CROSS
911400843OtherCOMMERCIAL
WA0168528OtherLABOR AND INDUSTRIES
4304HEOtherBLUE SHIELD
WA8341588Medicaid
WA8932338OtherCRIME VICTIMS INSURANCE
911400843OtherAETNA
911400843OtherBLUE CROSS