Provider Demographics
NPI:1396999579
Name:HENKE, LARA KATHRYN (MPT)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:KATHRYN
Last Name:HENKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4736 N PAULINA ST # F1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4435
Mailing Address - Country:US
Mailing Address - Phone:847-327-9113
Mailing Address - Fax:
Practice Address - Street 1:222 S RIVERSIDE PLZ STE 830
Practice Address - Street 2:SUPPLEMENTAL HEALTH CARE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-5900
Practice Address - Country:US
Practice Address - Phone:312-416-3804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.013946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist