Provider Demographics
NPI:1083264949
Name:HENRY, GAYLE (LCSW SEP)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:LCSW SEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 B ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1823
Mailing Address - Country:US
Mailing Address - Phone:619-822-4854
Mailing Address - Fax:
Practice Address - Street 1:2108 B ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-1823
Practice Address - Country:US
Practice Address - Phone:619-822-4854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA286981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty