Provider Demographics
NPI:1245500347
Name:HENLEY, LETITIA M
Entity type:Individual
Prefix:
First Name:LETITIA
Middle Name:M
Last Name:HENLEY
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:#22 CIELO VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VADITO
Mailing Address - State:NM
Mailing Address - Zip Code:87579
Mailing Address - Country:US
Mailing Address - Phone:575-587-1756
Mailing Address - Fax:
Practice Address - Street 1:#22 CIELO VISTA RD.
Practice Address - Street 2:INDIVIDUAL CLIENT HOMES;
Practice Address - City:VADITO
Practice Address - State:NM
Practice Address - Zip Code:87579
Practice Address - Country:US
Practice Address - Phone:575-587-1756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM#54222081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine