Healthcare Provider Details

I. General information

NPI: 1790845618
Provider Name (Legal Business Name): STEPHEN RUSSELL HENDERSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 WHITFIELD DR
BEDFORD VA
24523-1401
US

IV. Provider business mailing address

3300 RIVERMONT AVE
LYNCHBURG VA
24503-2030
US

V. Phone/Fax

Practice location:
  • Phone: 540-425-7670
  • Fax: 540-425-7675
Mailing address:
  • Phone: 434-200-5032
  • Fax: 434-200-1294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305004399
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: