Provider Demographics
NPI:1801264569
Name:HENDERSON, LAURA ANN (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 WARNER AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3846
Mailing Address - Country:US
Mailing Address - Phone:714-964-3337
Mailing Address - Fax:
Practice Address - Street 1:22 CORPORATE PLAZA DR
Practice Address - Street 2:SUITE 113
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7985
Practice Address - Country:US
Practice Address - Phone:949-722-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA430762251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic