Healthcare Provider Details

I. General information

NPI: 1780513135
Provider Name (Legal Business Name): MAKAYLA MARIE HENTHORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3656 MALL DR
EAU CLAIRE WI
54701-7634
US

IV. Provider business mailing address

11773 GOODWATER AVE
SPARTA WI
54656-8029
US

V. Phone/Fax

Practice location:
  • Phone: 715-552-1035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number435119
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: