Provider Demographics
NPI:1740667740
Name:HENDERSON, STERLING (DPT)
Entity type:Individual
Prefix:MR
First Name:STERLING
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3957 E 170 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5771
Mailing Address - Country:US
Mailing Address - Phone:801-368-7519
Mailing Address - Fax:
Practice Address - Street 1:3155 CHANNING WAY STE A
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7875
Practice Address - Country:US
Practice Address - Phone:208-522-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5893509-2401225100000X
ID4455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist