Provider Demographics
NPI:1114310968
Name:HENRY, REBECCA
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
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 1:1722 S LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8520
Mailing Address - Country:US
Mailing Address - Phone:818-209-1673
Mailing Address - Fax:
Practice Address - Street 1:1722 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:818-209-1673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN177582164X00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health