Provider Demographics
NPI:1568991024
Name:HENRIQUEZ, KISAIRA
Entity Type:Individual
Prefix:
First Name:KISAIRA
Middle Name:
Last Name:HENRIQUEZ
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 1:19 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2003
Mailing Address - Country:US
Mailing Address - Phone:201-220-5022
Mailing Address - Fax:
Practice Address - Street 1:56 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5131
Practice Address - Country:US
Practice Address - Phone:973-773-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist