Healthcare Provider Details

I. General information

NPI: 1639388259
Provider Name (Legal Business Name): ELIZABETH HENRY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIZ HENRY PT

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6752 PARKER FARM DR SUITE 1B
WILMINGTON NC
28405-3175
US

IV. Provider business mailing address

6752 PARKER FARM DR SUITE 1B
WILMINGTON NC
28405-3175
US

V. Phone/Fax

Practice location:
  • Phone: 910-679-4095
  • Fax: 910-338-1760
Mailing address:
  • Phone: 910-679-4095
  • Fax: 910-338-1760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberP12597
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberP12597
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: