Provider Demographics
NPI:1275714750
Name:EBEM, HENRY CHUKWUDI (PT)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:CHUKWUDI
Last Name:EBEM
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 1:2151 SETTLERS PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-4669
Mailing Address - Country:US
Mailing Address - Phone:512-552-7799
Mailing Address - Fax:512-472-2021
Practice Address - Street 1:3218 E MARTIN LUTHER KING JR BLVD STE 102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78721-1054
Practice Address - Country:US
Practice Address - Phone:512-472-2020
Practice Address - Fax:512-472-2021
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193315201Medicaid
TX193315201Medicaid
TX613135Medicare PIN
TX8F10161Medicare PIN