Provider Demographics
NPI:1508311515
Name:HENRY, THERESA (BACHLELOR)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:BACHLELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 WALTER ST
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-8113
Mailing Address - Country:US
Mailing Address - Phone:989-464-5224
Mailing Address - Fax:
Practice Address - Street 1:1275 WALTER ST # SR
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-8113
Practice Address - Country:US
Practice Address - Phone:989-464-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIH560792067962247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI247200000XOther247200000X/TECHNICAN-OTHER