Provider Demographics
NPI:1285632596
Name:HENRY, MATTHEW THOMAS (MPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:HENRY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E. OAK ST.
Mailing Address - Street 2:
Mailing Address - City:MC RAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-1550
Mailing Address - Country:US
Mailing Address - Phone:229-868-2174
Mailing Address - Fax:229-868-2175
Practice Address - Street 1:3051 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8536
Practice Address - Country:US
Practice Address - Phone:478-953-4563
Practice Address - Fax:478-953-4564
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008256225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA720012670AMedicaid
GA720012670AMedicaid