Provider Demographics
NPI:1902425598
Name:HENRY, BRITTANY NICOLE
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:NICOLE
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 W 3RD ST APT 321
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2655
Mailing Address - Country:US
Mailing Address - Phone:619-288-8349
Mailing Address - Fax:
Practice Address - Street 1:204 HAMPTON DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-8633
Practice Address - Country:US
Practice Address - Phone:323-961-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94631101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health