1013313485 NPI number — SUSAN JEAN HENRY BS, CLINICIAN I

Table of content: SUSAN JEAN HENRY BS, CLINICIAN I (NPI 1013313485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013313485 NPI number — SUSAN JEAN HENRY BS, CLINICIAN I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY
Provider First Name:
SUSAN
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BS, CLINICIAN I
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:
1013313485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 E EARLL DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-2647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-599-5404
Provider Business Mailing Address Fax Number:
602-599-5704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 W SOUTHERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85210-5032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-599-5526
Provider Business Practice Location Address Fax Number:
602-599-5487
Provider Enumeration Date:
11/13/2014

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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