1699287771 NPI number — MS. KEISHA MARIE HENRY WLS, CWC

Table of content: MS. KEISHA MARIE HENRY WLS, CWC (NPI 1699287771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699287771 NPI number — MS. KEISHA MARIE HENRY WLS, CWC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY
Provider First Name:
KEISHA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
WLS, CWC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENRY
Provider Other First Name:
MARIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
WLS, CWC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1699287771
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1309 ADCOX SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30088-4544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-460-9429
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3330 CUMBERLAND BLVD SE STE 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30339-5997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-242-9239
Provider Business Practice Location Address Fax Number:
770-933-6223
Provider Enumeration Date:
10/30/2017

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: 302R00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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