Provider Demographics
NPI:1346029956
Name:HENLEY, KRISTAL OLIVIA
Entity Type:Individual
Prefix:MRS
First Name:KRISTAL
Middle Name:OLIVIA
Last Name:HENLEY
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 1:3800 RENEE PL
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-3285
Mailing Address - Country:US
Mailing Address - Phone:229-630-0623
Mailing Address - Fax:
Practice Address - Street 1:3800 RENEE PL
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-3285
Practice Address - Country:US
Practice Address - Phone:229-630-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251E00000X
GAMSW011503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251E00000XAgenciesHome Health