Provider Demographics
NPI:1598742694
Name:BRENNER, HENDERSON B III (PT)
Entity Type:Individual
Prefix:MR
First Name:HENDERSON
Middle Name:B
Last Name:BRENNER
Suffix:III
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 1:950 J CLYDE MORRIS BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1004
Mailing Address - Country:US
Mailing Address - Phone:469-569-9407
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1602
Practice Address - Country:US
Practice Address - Phone:757-314-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1109718171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1109718OtherPHYSICAL THERAPY LICENSE