Healthcare Provider Details

I. General information

NPI: 1447655840
Provider Name (Legal Business Name): GENA HENDERSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 MENDELL CIR NE
ATLANTA GA
30319-2327
US

IV. Provider business mailing address

1092 MENDELL CIR NE
ATLANTA GA
30319-2327
US

V. Phone/Fax

Practice location:
  • Phone: 770-256-9921
  • Fax: 404-228-7107
Mailing address:
  • Phone: 770-256-9921
  • Fax: 404-228-7107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT011345
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: