Provider Demographics
NPI:1124898416
Name:HENDERSON, REBECCA ALICE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ALICE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ALICE
Other - Last Name:BAILLARGEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14555 SW 139TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-1401
Mailing Address - Country:US
Mailing Address - Phone:857-500-3387
Mailing Address - Fax:
Practice Address - Street 1:2149 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1580
Practice Address - Country:US
Practice Address - Phone:503-281-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27959225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist