MEDICARE: AMY HENDERSON DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT014223	GA

General Provider Information

NPI Number	:	1447860556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY HENDERSON DPT

Provider Business Mailing Address
First Line	:	1200 CORPORATE DR STE 400
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35242-5424
Country	:	US
Telephone Number	:	423-238-8907
Fax Number	:	423-954-7408

Provider Business Practice Location Address
First Line	:	3919 CARTER RD STE A
Second Line	:
City	:	BUFORD
State	:	GA
Zip	:	30518-1628
Country	:	US
Telephone Number	:	470-589-1058
Fax Number	:	470-589-1642

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2020
Last Update Date	:	08/04/2020

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