Healthcare Provider Details

I. General information

NPI: 1073557070
Provider Name (Legal Business Name): ROGER HENDERSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1954 ROCKLEDGE BLVD STE 119
ROCKLEDGE FL
32955-3761
US

IV. Provider business mailing address

2210 CHENEY HWY SUITE B
TITUSVILLE FL
32780-6702
US

V. Phone/Fax

Practice location:
  • Phone: 321-433-1500
  • Fax: 321-433-1556
Mailing address:
  • Phone: 321-745-7106
  • Fax: 321-267-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT19703
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT19703
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: