Basic Information
| Provider Information | |||||||||
| NPI: | 1518981422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | HOLLY | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7235 OHMS LN | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5298412345 | ||||||||
| FaxNumber: | 9528412346 | ||||||||
| Practice Location | |||||||||
| Address1: | 7235 OHMS LN | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5298412345 | ||||||||
| FaxNumber: | 9528412346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2353 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | HP44369 | 01 | MN | HEALTHPARTNERS | OTHER | 24373 | 01 | MN | AMERICA'S PPO | OTHER | 03A91HE | 01 | MN | BCBS OF MN | OTHER | 962871010735 | 01 | MN | PREFERRED ONE | OTHER | 6402798 | 01 | MN | MEDICA | OTHER |