Provider Demographics
NPI:1831320373
Name:HENRY, LAURA B (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:B
Last Name:HENRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 I 55 SERVICE RD
Mailing Address - Street 2:STE C
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72301
Mailing Address - Country:US
Mailing Address - Phone:870-739-8686
Mailing Address - Fax:870-739-8656
Practice Address - Street 1:2860 I 55 SERVICE RD
Practice Address - Street 2:STE C
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-739-8686
Practice Address - Fax:870-739-8656
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2338225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR178268721Medicaid