Provider Demographics
NPI:1073157129
Name:HENSON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3313
Mailing Address - Country:US
Mailing Address - Phone:719-469-6875
Mailing Address - Fax:
Practice Address - Street 1:265 S HARLAN ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-2261
Practice Address - Country:US
Practice Address - Phone:720-272-1289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician