Provider Demographics
NPI:1952652612
Name:HENRY, TALISHA
Entity Type:Individual
Prefix:
First Name:TALISHA
Middle Name:
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:PO BOX 285
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08010-0285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7901 METROPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-3111
Practice Address - Country:US
Practice Address - Phone:800-423-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2024-01-31
Deactivation Date:2020-01-08
Deactivation Code:
Reactivation Date:2020-01-14
Provider Licenses
StateLicense IDTaxonomies
TX1099491041C0700X
NJ44SLO6469100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker