Provider Demographics
NPI:1104121821
Name:HENDLEY, BRIAN MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MATTHEW
Last Name:HENDLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W BEACON STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-650-9902
Practice Address - Street 1:2990 HWY 49S
Practice Address - Street 2:SUITE A
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073
Practice Address - Country:US
Practice Address - Phone:601-891-8179
Practice Address - Fax:601-891-8520
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS640881013172V00000X
MSPT2731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0220392Medicaid