Provider Demographics
NPI:1902450455
Name:HENRY, TRACEY ANORA
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANORA
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 1:3675 PECOS MECLEOD STE 900
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121
Mailing Address - Country:US
Mailing Address - Phone:702-538-7412
Mailing Address - Fax:702-538-7418
Practice Address - Street 1:3675 PECOS MECLEOD STE 900
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121
Practice Address - Country:US
Practice Address - Phone:702-538-7412
Practice Address - Fax:702-538-7418
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12111-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)