Provider Demographics
NPI:1629454749
Name:HENRY, MARK R (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:HENRY
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 1:2405 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2184
Mailing Address - Country:US
Mailing Address - Phone:434-485-8500
Mailing Address - Fax:434-485-8599
Practice Address - Street 1:2405 ATHERHOLT RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2184
Practice Address - Country:US
Practice Address - Phone:434-485-8500
Practice Address - Fax:434-485-8599
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629454749Medicaid
VA1366815599Medicaid
Q50767BMedicare PIN
VA1629454749Medicaid
VAQ50767AMedicare PIN
Q51793BMedicare PIN
P01598571Medicare PIN