Provider Demographics
NPI:1356952576
Name:HENDERSON, TAYLOR KONDO (PT, DPT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:KONDO
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:KONDO
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:925 CARIBOU CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-8424
Mailing Address - Country:US
Mailing Address - Phone:951-314-6191
Mailing Address - Fax:
Practice Address - Street 1:25255 CABOT RD STE 112
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5507
Practice Address - Country:US
Practice Address - Phone:949-229-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist