Basic Information
| Provider Information | |||||||||
| NPI: | 1780926105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PREWITT | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 27950 S HIGHWAY 125 | ||||||||
| Address2: | UNIT 39 | ||||||||
| City: | MONKEY ISLAND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743313124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139569032 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4812 E 33RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224126 | ||||||||
| FaxNumber: | 9182702398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2013 | ||||||||
| LastUpdateDate: | 05/25/2017 | ||||||||
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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 | 2251X0800X | 2013008000 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 2251X0800X | 11-04532 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 5012 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.