Provider Demographics
NPI:1508149717
Name:HENKE, CONNIE LYNN (SLP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LYNN
Last Name:HENKE
Suffix:
Gender:F
Credentials:SLP
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 207
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-0207
Mailing Address - Country:US
Mailing Address - Phone:845-255-4990
Mailing Address - Fax:
Practice Address - Street 1:156 ROUTE 302
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-7130
Practice Address - Country:US
Practice Address - Phone:845-744-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018843-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist