Healthcare Provider Details

I. General information

NPI: 1265944656
Provider Name (Legal Business Name): KRISTEN HENDERSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

7500 BATKIN CT
COTATI CA
94931-4167
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-2311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number17844
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: