Provider Demographics
NPI:1497993174
Name:HENEBRY, MARK W (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:HENEBRY
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 1:108 PROFESSIONAL PARKWAY DR.
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2823
Mailing Address - Country:US
Mailing Address - Phone:636-528-6080
Mailing Address - Fax:636-528-3973
Practice Address - Street 1:108 PROFESSIONAL PARKWAY DR.
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2823
Practice Address - Country:US
Practice Address - Phone:636-528-6080
Practice Address - Fax:636-528-3973
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009002205225100000X
MO2009004293225100000X
IL070017005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO150250002Medicare PIN