Provider Demographics
NPI:1861919623
Name:KHOURY, CLINTON T (PT)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:T
Last Name:KHOURY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 EXECUTIVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292
Mailing Address - Country:US
Mailing Address - Phone:941-485-1505
Mailing Address - Fax:
Practice Address - Street 1:3030 EXECUTIVE DRIVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292
Practice Address - Country:US
Practice Address - Phone:941-485-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT37264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist