Provider Demographics
NPI:1881793388
Name:HENDERSON, MARY H (PTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17173 PINE CIRCLE RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-6135
Mailing Address - Country:US
Mailing Address - Phone:218-829-4231
Mailing Address - Fax:218-825-3855
Practice Address - Street 1:224 N 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3348
Practice Address - Country:US
Practice Address - Phone:218-829-4231
Practice Address - Fax:218-825-3855
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND550225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant