Provider Demographics
NPI:1649494667
Name:HENRY, MARK ANGELO SR (LPTA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANGELO
Last Name:HENRY
Suffix:SR
Gender:M
Credentials:LPTA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 720794
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-0794
Mailing Address - Country:US
Mailing Address - Phone:601-319-6466
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:601-605-8869
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA3317225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant