Provider Demographics
NPI:1194334946
Name:EMBRY, JUSTIN (PT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:EMBRY
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 1:124 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9430
Mailing Address - Country:US
Mailing Address - Phone:317-332-9861
Mailing Address - Fax:317-893-4453
Practice Address - Street 1:124 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9430
Practice Address - Country:US
Practice Address - Phone:317-332-9861
Practice Address - Fax:317-893-4453
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008230A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3163Medicaid