Provider Demographics
NPI:1710490818
Name:HENDRYCY, MARIANNA CLO (PT)
Entity Type:Individual
Prefix:
First Name:MARIANNA
Middle Name:CLO
Last Name:HENDRYCY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 E MANOR DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-2624
Mailing Address - Country:US
Mailing Address - Phone:479-530-6311
Mailing Address - Fax:
Practice Address - Street 1:1830 N CROSSOVER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-2725
Practice Address - Country:US
Practice Address - Phone:479-530-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1014261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy