Basic Information
| Provider Information | |||||||||
| NPI: | 1104121821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDLEY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 W BEACON STREET | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016500002 | ||||||||
| FaxNumber: | 6016509902 | ||||||||
| Practice Location | |||||||||
| Address1: | 2990 HWY 49S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FLORENCE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018918179 | ||||||||
| FaxNumber: | 6018918520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2011 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 640881013 | MS | N | Other Service Providers | Community Health Worker | 225100000X | PT2731 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0220392 | 05 | MS | MEDICAID |