Provider Demographics
NPI:1831947167
Name:HENSON, ANGELLE
Entity type:Individual
Prefix:
First Name:ANGELLE
Middle Name:
Last Name:HENSON
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 1:343 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-2165
Mailing Address - Country:US
Mailing Address - Phone:618-772-8898
Mailing Address - Fax:
Practice Address - Street 1:4200 N CLOVERLEAF DR STE J
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-6436
Practice Address - Country:US
Practice Address - Phone:636-922-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024016293225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics