Provider Demographics
NPI:1649321613
Name:HENDERSON, KATHRYN STOGNER (PT)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:STOGNER
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:JOYCE
Other - Last Name:STOGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 REINHARDT COURT
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6319
Mailing Address - Country:US
Mailing Address - Phone:512-868-1183
Mailing Address - Fax:
Practice Address - Street 1:204 S IH35 SUITE 203
Practice Address - Street 2:GEORGETOWN PHYSICAL THERAPY
Practice Address - City:GEORGETOWN
Practice Address - State:NC
Practice Address - Zip Code:78628
Practice Address - Country:US
Practice Address - Phone:512-863-7761
Practice Address - Fax:512-863-0973
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1167457225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
676548Medicare ID - Type Unspecified
IL146636Medicare ID - Type Unspecified