Provider Demographics
NPI:1184984270
Name:HENDERSON, JOEL BRENT (PTA)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:BRENT
Last Name:HENDERSON
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 1:411 WALNUT ST
Mailing Address - Street 2:#8650
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3443
Mailing Address - Country:US
Mailing Address - Phone:864-353-9467
Mailing Address - Fax:
Practice Address - Street 1:1206 N TRAVIS ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3540
Practice Address - Country:US
Practice Address - Phone:936-336-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2081113225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant