Provider Demographics
NPI:1558516898
Name:HENRY, BRIANA NICOLE
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:NICOLE
Last Name:HENRY
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 1:17800 HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1221
Mailing Address - Country:US
Mailing Address - Phone:760-242-6336
Mailing Address - Fax:760-946-0819
Practice Address - Street 1:17800 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2121
Practice Address - Country:US
Practice Address - Phone:760-242-6336
Practice Address - Fax:760-946-0819
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78408106H00000X
CA104847106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist