Basic Information
| Provider Information | |||||||||
| NPI: | 1033496906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | ATC, MSED, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 PEMBROKE CIR APT D | ||||||||
| Address2: | |||||||||
| City: | WAPPINGERS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125905649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455942985 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 WEBSTER AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126011363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454548377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2011 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 001693 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.