Provider Demographics
NPI:1992173736
Name:HENDERSON, SHARON
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 MISSOURI 109
Mailing Address - Street 2:EUREKA HIGH SCHOOL
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4525 MISSOURI 109
Practice Address - Street 2:EUREKA HIGH SCHOOL
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025
Practice Address - Country:US
Practice Address - Phone:636-733-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120289592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer