Provider Demographics
NPI:1043463714
Name:HENRY, MICHAEL RAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
Last Name:HENRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5235
Mailing Address - Street 2:6271 PLEASANTS VALLEY ROAD
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95696-5235
Mailing Address - Country:US
Mailing Address - Phone:858-449-6301
Mailing Address - Fax:
Practice Address - Street 1:831 ALAMO DR STE 6B
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688
Practice Address - Country:US
Practice Address - Phone:707-624-9767
Practice Address - Fax:707-471-4140
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLP3321103TC0700X
CO9724103TC0700X
CAPSY22614103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical