Basic Information
| Provider Information | |||||||||
| NPI: | 1013232206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENN | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2874 N CARSON ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897060251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758834161 | ||||||||
| FaxNumber: | 7758837742 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 PENNY LN | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950763079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317869000 | ||||||||
| FaxNumber: | 8317869100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT20496 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT20496 | 01 | CA | LICENSE | OTHER |