Provider Demographics
NPI:1831880152
Name:HENDERSON, KRISJAN MIKKEL (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KRISJAN
Middle Name:MIKKEL
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 KENT CIR APT 7
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-4479
Mailing Address - Country:US
Mailing Address - Phone:515-829-6540
Mailing Address - Fax:
Practice Address - Street 1:604 ANSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-5842
Practice Address - Country:US
Practice Address - Phone:319-433-0130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1331262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty