Provider Demographics
NPI:1104231919
Name:HENRIKSON, MELISSA JO (LMT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JO
Last Name:HENRIKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 380
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:IL
Mailing Address - Zip Code:62684-0380
Mailing Address - Country:US
Mailing Address - Phone:217-496-3636
Mailing Address - Fax:217-496-3838
Practice Address - Street 1:420 CROSSING DR
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:IL
Practice Address - Zip Code:62684-9640
Practice Address - Country:US
Practice Address - Phone:217-496-3636
Practice Address - Fax:217-496-3838
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.003885225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist