Provider Demographics
NPI:1871192856
Name:HENLEY, THEADORE JOSEPH (QSP)
Entity Type:Individual
Prefix:
First Name:THEADORE
Middle Name:JOSEPH
Last Name:HENLEY
Suffix:
Gender:M
Credentials:QSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 2ND ST
Mailing Address - Street 2:
Mailing Address - City:REEDER
Mailing Address - State:ND
Mailing Address - Zip Code:58649-4939
Mailing Address - Country:US
Mailing Address - Phone:701-498-0731
Mailing Address - Fax:
Practice Address - Street 1:604 2ND ST
Practice Address - Street 2:
Practice Address - City:REEDER
Practice Address - State:ND
Practice Address - Zip Code:58649-4939
Practice Address - Country:US
Practice Address - Phone:701-498-0731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1477909Medicaid