Provider Demographics
NPI:1982234407
Name:HENRY, JUSTIN EDWARD
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:EDWARD
Last Name:HENRY
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 1:75 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:DEATSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36022-3135
Mailing Address - Country:US
Mailing Address - Phone:334-730-5778
Mailing Address - Fax:
Practice Address - Street 1:75 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:DEATSVILLE
Practice Address - State:AL
Practice Address - Zip Code:36022-3135
Practice Address - Country:US
Practice Address - Phone:334-730-5778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12692390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program