Provider Demographics
NPI:1720682123
Name:HENDERSHOT, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:HENDERSHOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8194 SHIELDS DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609-4813
Mailing Address - Country:US
Mailing Address - Phone:248-904-6883
Mailing Address - Fax:
Practice Address - Street 1:1381 CLEAVER RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9135
Practice Address - Country:US
Practice Address - Phone:989-673-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7151001758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist