=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790409720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARENCE TIMOTHY HENERY PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2022
-----------------------------------------------------
Last Update Date | 10/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 S CHICKASAW TRL
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-208-1690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 S CHICKASAW TRL
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-208-1690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 20235
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------