Provider Demographics
NPI:1093015208
Name:HENRY, LEVI ALFORD (MA, PPS)
Entity type:Individual
Prefix:MR
First Name:LEVI
Middle Name:ALFORD
Last Name:HENRY
Suffix:
Gender:M
Credentials:MA, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4775 HIDALGO AVE.
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422
Mailing Address - Country:US
Mailing Address - Phone:805-458-6852
Mailing Address - Fax:
Practice Address - Street 1:402 FARNELL ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-4960
Practice Address - Country:US
Practice Address - Phone:805-922-0334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool