Provider Demographics
NPI:1962210161
Name:HENDERSON, KELLI (PTA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:MCCAULEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:15209 SERENADE DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5500
Mailing Address - Country:US
Mailing Address - Phone:407-538-4375
Mailing Address - Fax:
Practice Address - Street 1:1804 OAKLEY SEAVER DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1925
Practice Address - Country:US
Practice Address - Phone:352-989-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30734225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant