Healthcare Provider Details

I. General information

NPI: 1629049739
Provider Name (Legal Business Name): MARK L HENISER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR BROOKE ARMY MEDICAL CENTER AMPUTEE PHYSICAL THERAPY
FORT SAM HOUSTON TX
78234-4501
US

IV. Provider business mailing address

964 PERSIAN GDN
SAN ANTONIO TX
78258-6658
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-5048
  • Fax: 210-916-4074
Mailing address:
  • Phone: 210-916-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501011867
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14873
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1159200
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: