Basic Information
| Provider Information | |||||||||
| NPI: | 1073133385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDRICK | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 READING AVE APT 412 | ||||||||
| Address2: | |||||||||
| City: | WEST READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196111284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4347746720 | ||||||||
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| Practice Location | |||||||||
| Address1: | 590 S 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170429195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172740421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2020 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | PT028190 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
ID Information
| ID | Type | State | Issuer | Description | PT028190 | 01 | PA | PHYSICAL THERAPIST STATE LICENSE | OTHER |