Provider Demographics
NPI:1699797829
Name:HENRICH, MARK DAVID (PT,MBA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:HENRICH
Suffix:
Gender:M
Credentials:PT,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TRACY WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1257
Mailing Address - Country:US
Mailing Address - Phone:304-343-4583
Mailing Address - Fax:304-343-9207
Practice Address - Street 1:100 TRACY WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1257
Practice Address - Country:US
Practice Address - Phone:304-343-4583
Practice Address - Fax:304-343-9207
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9223731Medicare PIN