Provider Demographics
NPI:1366711061
Name:HENDERSON, CONNIE LOUISE
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LOUISE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CONNIE
Other - Middle Name:LOUISE
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1239 120TH AVE NE
Mailing Address - Street 2:SUITE E
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2133
Mailing Address - Country:US
Mailing Address - Phone:425-467-7105
Mailing Address - Fax:
Practice Address - Street 1:1239 120TH AVE NE
Practice Address - Street 2:SUITE E
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2133
Practice Address - Country:US
Practice Address - Phone:425-467-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 00003570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist