Provider Demographics
NPI:1790845618
Name:HENDERSON, STEPHEN RUSSELL (PT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RUSSELL
Last Name:HENDERSON
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3300 RIVERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2030
Mailing Address - Country:US
Mailing Address - Phone:434-200-5032
Mailing Address - Fax:434-200-1294
Practice Address - Street 1:1710 WHITFIELD DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-1401
Practice Address - Country:US
Practice Address - Phone:540-425-7670
Practice Address - Fax:540-425-7675
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist