Healthcare Provider Details

I. General information

NPI: 1407372782
Provider Name (Legal Business Name): MICHELLE HENAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N HUMPHREYS BLVD
MEMPHIS TN
38120-2146
US

IV. Provider business mailing address

100 N HUMPHREYS BLVD
MEMPHIS TN
38120-2146
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-1800
  • Fax: 901-747-1801
Mailing address:
  • Phone: 901-747-1800
  • Fax: 901-747-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11568
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12045
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: