Basic Information
| Provider Information | |||||||||
| NPI: | 1891459178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6130 CARVEL AVE APT 3 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462202089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732280991 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3114 E 46TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462052413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179207888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2021 | ||||||||
| LastUpdateDate: | 10/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05014188A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 208100000X | 05014188A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.