Provider Demographics
NPI:1508218736
Name:HENNEKE, PHILIP (MA, QMHP)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:HENNEKE
Suffix:
Gender:M
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 N. LAURENT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901
Mailing Address - Country:US
Mailing Address - Phone:361-893-8734
Mailing Address - Fax:361-894-8735
Practice Address - Street 1:1802 N. LAURENT
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901
Practice Address - Country:US
Practice Address - Phone:361-893-8734
Practice Address - Fax:361-894-8735
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator