Provider Demographics
NPI:1770923187
Name:HENDRICKSON, HEIDI JO (LAT, ATC)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:JO
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 S JAMES AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2151
Mailing Address - Country:US
Mailing Address - Phone:509-431-3338
Mailing Address - Fax:
Practice Address - Street 1:6200 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SNYDER
Practice Address - State:TX
Practice Address - Zip Code:79549-6105
Practice Address - Country:US
Practice Address - Phone:509-431-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT5588390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program