Provider Demographics
NPI:1790409720
Name:HENERY, CLARENCE TIMOTHY (PTA)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:TIMOTHY
Last Name:HENERY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S CHICKASAW TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3503
Mailing Address - Country:US
Mailing Address - Phone:407-208-1690
Mailing Address - Fax:
Practice Address - Street 1:250 S CHICKASAW TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3503
Practice Address - Country:US
Practice Address - Phone:407-208-1690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20235225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant