Provider Demographics
NPI:1730693342
Name:HENRIQUEZ, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:HENRIQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27856 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2730
Mailing Address - Country:US
Mailing Address - Phone:248-210-0146
Mailing Address - Fax:
Practice Address - Street 1:6271 SCHAEFER RD STE 102
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2210
Practice Address - Country:US
Practice Address - Phone:313-652-6701
Practice Address - Fax:313-652-6701
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician