Provider Demographics
NPI:1598817785
Name:HENSON, KEITH JOHN
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:JOHN
Last Name:HENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N MILES ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1834
Mailing Address - Country:US
Mailing Address - Phone:270-360-9129
Mailing Address - Fax:270-234-8197
Practice Address - Street 1:4331 CHURCHMAN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1164
Practice Address - Country:US
Practice Address - Phone:502-366-1773
Practice Address - Fax:502-366-3500
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004602225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000340690OtherBLUE CROSS
0706306Medicare ID - Type Unspecified