Provider Demographics
NPI:1881996460
Name:HENRY, BRENDA LEE (RT (R))
Entity type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:LEE
Last Name:HENRY
Suffix:
Gender:F
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 EDGAR ST
Mailing Address - Street 2:
Mailing Address - City:WOLF POINT
Mailing Address - State:MT
Mailing Address - Zip Code:59201-1726
Mailing Address - Country:US
Mailing Address - Phone:406-653-2708
Mailing Address - Fax:
Practice Address - Street 1:107 H. ST
Practice Address - Street 2:VERNE.E GIBBS HEALTH CENTER
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255
Practice Address - Country:US
Practice Address - Phone:406-768-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2836247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist