Provider Demographics
NPI:1396070538
Name:HENDERSON, HEATHER J (DPT)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 WELLS AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4524
Mailing Address - Country:US
Mailing Address - Phone:208-789-0200
Mailing Address - Fax:208-288-2784
Practice Address - Street 1:1626 WELLS AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4524
Practice Address - Country:US
Practice Address - Phone:208-789-0200
Practice Address - Fax:208-288-2784
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1396070538OtherNPI
ID20006238Medicare UPIN