Provider Demographics
NPI:1952065351
Name:HENRY, EVITA A
Entity Type:Individual
Prefix:
First Name:EVITA
Middle Name:A
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 1:1622 BROOKDALE RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2127
Mailing Address - Country:US
Mailing Address - Phone:847-418-1432
Mailing Address - Fax:
Practice Address - Street 1:1622 BROOKDALE RD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-2127
Practice Address - Country:US
Practice Address - Phone:847-418-1432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health