Healthcare Provider Details

I. General information

NPI: 1801667266
Provider Name (Legal Business Name): KELLY HENDERSON RRT, CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 BROADWAY FL 3
OAKLAND CA
94611-5730
US

IV. Provider business mailing address

3600 BROADWAY FL 3
OAKLAND CA
94611-5730
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-5242
  • Fax:
Mailing address:
  • Phone: 510-752-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number39466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: