Healthcare Provider Details

I. General information

NPI: 1699803882
Provider Name (Legal Business Name): ANDREA M. HENRY P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E NAPLES ST
CHULA VISTA CA
91911-2519
US

IV. Provider business mailing address

1559 FALLING STAR DR
CHULA VISTA CA
91915-1809
US

V. Phone/Fax

Practice location:
  • Phone: 619-421-6083
  • Fax:
Mailing address:
  • Phone: 619-941-2958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number24258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: