Basic Information
| Provider Information | |||||||||
| NPI: | 1649494667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANGELO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720794 | ||||||||
| Address2: | |||||||||
| City: | BYRAM | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392720794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013196466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | 6016058869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA3317 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.