Provider Demographics
NPI:1639338882
Name:HENRY, DIANE M
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
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 1:5504 BURGUNDY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-3306
Mailing Address - Country:US
Mailing Address - Phone:512-736-4158
Mailing Address - Fax:
Practice Address - Street 1:5504 BURGUNDY DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78724-3306
Practice Address - Country:US
Practice Address - Phone:512-736-4158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor