Provider Demographics
NPI:1629049739
Name:HENISER, MARK L (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:HENISER
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 1:964 PERSIAN GDN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-6658
Mailing Address - Country:US
Mailing Address - Phone:210-916-5048
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:BROOKE ARMY MEDICAL CENTER AMPUTEE PHYSICAL THERAPY
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:210-916-5048
Practice Address - Fax:210-916-4074
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501011867225100000X
CA14873225100000X
TX1159200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist