Provider Demographics
NPI:1336315654
Name:HENRY, KENNETH RAY
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RAY
Last Name:HENRY
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 1:1937 W CHAPMAN AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2633
Mailing Address - Country:US
Mailing Address - Phone:714-385-5260
Mailing Address - Fax:
Practice Address - Street 1:1937 W CHAPMAN AVE STE 220
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2633
Practice Address - Country:US
Practice Address - Phone:714-385-5260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health