Provider Demographics
NPI:1689193625
Name:HENRIQUEZ, MARLENE
Entity Type:Individual
Prefix:
First Name:MARLENE
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 1:3399 E GRAND RIVER AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-7555
Mailing Address - Country:US
Mailing Address - Phone:743-368-9770
Mailing Address - Fax:
Practice Address - Street 1:3399 E GRAND RIVER AVE STE 102
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-7555
Practice Address - Country:US
Practice Address - Phone:743-368-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician