Provider Demographics
NPI:1164963260
Name:HENRY, BARBARA
Entity Type:Individual
Prefix:
First Name:BARBARA
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:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-1001
Mailing Address - Country:US
Mailing Address - Phone:662-641-6835
Mailing Address - Fax:662-757-9057
Practice Address - Street 1:223 BEAVER DAM RD
Practice Address - Street 2:
Practice Address - City:TUTWILER
Practice Address - State:MS
Practice Address - Zip Code:38963-5229
Practice Address - Country:US
Practice Address - Phone:662-641-6835
Practice Address - Fax:662-757-9057
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS81-0688451Medicaid