Healthcare Provider Details

I. General information

NPI: 1245410323
Provider Name (Legal Business Name): CORNELIUS HENDERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

IV. Provider business mailing address

1944 KATY FORT BEND RD APT 5106
KATY TX
77493-4797
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-6777
  • Fax: 601-605-8869
Mailing address:
  • Phone: 281-900-9430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA3890
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1301027
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: