Provider Demographics
NPI:1710499025
Name:HENLEY, TEVIN BERNARD
Entity Type:Individual
Prefix:
First Name:TEVIN
Middle Name:BERNARD
Last Name:HENLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9428 BROOKLINE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1428
Mailing Address - Country:US
Mailing Address - Phone:225-372-2693
Mailing Address - Fax:
Practice Address - Street 1:9428 BROOKLINE AVE STE 2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1428
Practice Address - Country:US
Practice Address - Phone:225-372-2693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA743219772Medicaid