1134341076 NPI number — DR. KEISHA DENYTHIA HENRY PH.D.

Table of content: DR. KEISHA DENYTHIA HENRY PH.D. (NPI 1134341076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134341076 NPI number — DR. KEISHA DENYTHIA HENRY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY
Provider First Name:
KEISHA
Provider Middle Name:
DENYTHIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134341076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-987-7338
Provider Business Mailing Address Fax Number:
501-987-8087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 MEDICAL GROUP, LIFE SKILLS SUPPORT CENTER
Provider Second Line Business Practice Location Address:
1090 ARNOLD DRIVE
Provider Business Practice Location Address City Name:
LITTLE ROCK AFB
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-987-7338
Provider Business Practice Location Address Fax Number:
501-987-8087
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1433 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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