Provider Demographics
NPI:1780926105
Name:HENDRICKS, MICHELLE RENEE (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:PREWITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27950 S HIGHWAY 125
Mailing Address - Street 2:UNIT 39
Mailing Address - City:MONKEY ISLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74331-3124
Mailing Address - Country:US
Mailing Address - Phone:913-956-9032
Mailing Address - Fax:
Practice Address - Street 1:4812 E 33RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2038
Practice Address - Country:US
Practice Address - Phone:918-622-4126
Practice Address - Fax:918-270-2398
Is Sole Proprietor?:No
Enumeration Date:2013-03-24
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130080002251X0800X
KS11-045322251X0800X
OK5012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic