Provider Demographics
NPI:1841503422
Name:HENNINGS, MATTHEW BRADLEY (PT, DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRADLEY
Last Name:HENNINGS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LIBERTY ST SE STE 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5385
Mailing Address - Country:US
Mailing Address - Phone:503-500-5727
Mailing Address - Fax:
Practice Address - Street 1:1100 LIBERTY ST SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5385
Practice Address - Country:US
Practice Address - Phone:503-500-5727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6457225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist