Provider Demographics
NPI:1174790265
Name:HENDERSON, GILBERT (LPT)
Entity type:Individual
Prefix:
First Name:GILBERT
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SAINT MARKS PL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-1251
Mailing Address - Country:US
Mailing Address - Phone:979-242-2401
Mailing Address - Fax:
Practice Address - Street 1:2 SAINT MARKS PL
Practice Address - Street 2:SUITE 120
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1251
Practice Address - Country:US
Practice Address - Phone:979-242-2401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1059640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist