Provider Demographics
NPI:1356818744
Name:HENDERSON, CHRISTA R
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:R
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 OLD BARN CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4045
Mailing Address - Country:US
Mailing Address - Phone:317-507-5853
Mailing Address - Fax:
Practice Address - Street 1:6301 OLD BARN CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-4045
Practice Address - Country:US
Practice Address - Phone:317-507-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
IN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator