Provider Demographics
NPI:1356026819
Name:HENSON, KEONI K
Entity type:Individual
Prefix:
First Name:KEONI
Middle Name:K
Last Name:HENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 CARSON PASS CT
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-1877
Mailing Address - Country:US
Mailing Address - Phone:775-412-2351
Mailing Address - Fax:
Practice Address - Street 1:1711 E BARNACLE AVE
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119-3796
Practice Address - Country:US
Practice Address - Phone:775-412-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities