Provider Demographics
NPI:1003463449
Name:HENRY, BRICKNEY
Entity Type:Individual
Prefix:
First Name:BRICKNEY
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 NINE OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-2533
Mailing Address - Country:US
Mailing Address - Phone:516-497-8012
Mailing Address - Fax:
Practice Address - Street 1:652 NINE OAKS CIR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-2533
Practice Address - Country:US
Practice Address - Phone:516-497-8012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care