Provider Demographics
NPI:1477825610
Name:HENRY, TEENA D (BHRS)
Entity Type:Individual
Prefix:
First Name:TEENA
Middle Name:D
Last Name:HENRY
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29364 COUNTY ROAD 1610
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:OK
Mailing Address - Zip Code:74572-5047
Mailing Address - Country:US
Mailing Address - Phone:580-310-2568
Mailing Address - Fax:
Practice Address - Street 1:705 W 13TH ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3712
Practice Address - Country:US
Practice Address - Phone:580-889-5555
Practice Address - Fax:580-889-1925
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid