Provider Demographics
NPI:1265277685
Name:HENRY, GLORIA LYNN
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:LYNN
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 1:6190 THE LAKES DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4615
Mailing Address - Country:US
Mailing Address - Phone:404-452-9808
Mailing Address - Fax:
Practice Address - Street 1:6190 THE LAKES DR
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4615
Practice Address - Country:US
Practice Address - Phone:404-452-9808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician