Healthcare Provider Details

I. General information

NPI: 1942835053
Provider Name (Legal Business Name): LYDIA JEANNETTE HENDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 BALLARD RD
PARK RIDGE IL
60068-1005
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-2444
  • Fax: 847-318-2583
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-179477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: