Provider Demographics
NPI:1992397582
Name:HENRY, ROBERTA A
Entity Type:Individual
Prefix:
First Name:ROBERTA
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 1:105 WINFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4528
Mailing Address - Country:US
Mailing Address - Phone:831-222-5636
Mailing Address - Fax:
Practice Address - Street 1:8030 SOQUEL AVE STE 103
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2096
Practice Address - Country:US
Practice Address - Phone:831-476-1747
Practice Address - Fax:831-476-1125
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)