Provider Demographics
NPI:1477090355
Name:HENDERSON, SHARON A (LMT)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 693
Mailing Address - Street 2:
Mailing Address - City:MEDANALES
Mailing Address - State:NM
Mailing Address - Zip Code:87548-0693
Mailing Address - Country:US
Mailing Address - Phone:505-570-9984
Mailing Address - Fax:
Practice Address - Street 1:82 COUNTY ROAD 122
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3187
Practice Address - Country:US
Practice Address - Phone:505-753-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8503225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist