Provider Demographics
NPI:1881631653
Name:GOCKENBACH, HENRY ALLEN (PT, ATC)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:ALLEN
Last Name:GOCKENBACH
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3761 SW WYCOFF ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5318
Mailing Address - Country:US
Mailing Address - Phone:772-532-1834
Mailing Address - Fax:772-464-3365
Practice Address - Street 1:3761 SW WYCOFF ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5318
Practice Address - Country:US
Practice Address - Phone:772-532-1834
Practice Address - Fax:772-464-3365
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2008-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19109225100000X
FLAL11422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer