Provider Demographics
NPI:1457938730
Name:HENLEY, ELIZABETH TARA
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:TARA
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 1:39724 FOX VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1533
Mailing Address - Country:US
Mailing Address - Phone:734-812-8641
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR.
Practice Address - Street 2:SUITE 4001
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program