Provider Demographics
NPI:1386614865
Name:HENNEN, WAYNE (RPT)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:HENNEN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216-8237
Mailing Address - Country:US
Mailing Address - Phone:605-541-1140
Mailing Address - Fax:605-541-0109
Practice Address - Street 1:900 2ND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MN
Practice Address - Zip Code:56256-1006
Practice Address - Country:US
Practice Address - Phone:320-598-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD625225100000X
MN5338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5835010Medicaid
SDP93701Medicare UPIN
SD5835010Medicaid