Provider Demographics
NPI:1023517638
Name:HENAULT, CORBIN B (MED, ATC)
Entity type:Individual
Prefix:
First Name:CORBIN
Middle Name:B
Last Name:HENAULT
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 KINGSTOWN DR APT 78
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-2364
Mailing Address - Country:US
Mailing Address - Phone:408-679-7133
Mailing Address - Fax:
Practice Address - Street 1:3219 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5254
Practice Address - Country:US
Practice Address - Phone:912-358-3439
Practice Address - Fax:912-358-3939
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0025902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer