Provider Demographics
NPI:1861475675
Name:MCHENRY, DAVID VANCE (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:VANCE
Last Name:MCHENRY
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 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:4829 NE MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3351
Practice Address - Country:US
Practice Address - Phone:503-283-8133
Practice Address - Fax:503-289-2312
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182974Medicaid
OR182974Medicaid