Basic Information
| Provider Information | |||||||||
| NPI: | 1801430236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2021 LAKE HIGHLAND E | ||||||||
| Address2: | |||||||||
| City: | QUINLAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754745163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032695360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1414 COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | SULPHUR SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754823431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034390107 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2019 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2141462 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.