Provider Demographics
NPI:1558159517
Name:HENRIQUEZ, ALYSSA ANA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANA
Last Name:HENRIQUEZ
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12395 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-6600
Mailing Address - Country:US
Mailing Address - Phone:760-634-1125
Mailing Address - Fax:
Practice Address - Street 1:12395 LEWIS ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-6600
Practice Address - Country:US
Practice Address - Phone:760-634-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician