Provider Demographics
NPI:1457724262
Name:HENNEKE, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:HENNEKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 LIDO LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77092-4314
Mailing Address - Country:US
Mailing Address - Phone:512-659-6090
Mailing Address - Fax:
Practice Address - Street 1:17360 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:JERSEY VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:77040-1114
Practice Address - Country:US
Practice Address - Phone:713-849-2253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT36212255A2300X
TX117121225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer