Provider Demographics
NPI:1902931520
Name:HENDRICKSON, TERRI LYNNE (DT)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:LYNNE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W CEDARVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9155
Mailing Address - Country:US
Mailing Address - Phone:815-563-4331
Mailing Address - Fax:815-563-4331
Practice Address - Street 1:624 W CEDARVILLE RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9155
Practice Address - Country:US
Practice Address - Phone:815-563-4331
Practice Address - Fax:815-563-4331
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILTH85270993P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist