Healthcare Provider Details

I. General information

NPI: 1508696931
Provider Name (Legal Business Name): CHARITY JOY HENDRICKSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ
LAKE ST LOUIS MO
63367-1366
US

IV. Provider business mailing address

4539 CAMBROOK DR
SAINT CHARLES MO
63304-8713
US

V. Phone/Fax

Practice location:
  • Phone: 636-755-3610
  • Fax:
Mailing address:
  • Phone: 815-222-7689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2010023236
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: