Provider Demographics
NPI:1114065091
Name:HENRY, GARY JAMES
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JAMES
Last Name:HENRY
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 1:9268 SE CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1456
Mailing Address - Country:US
Mailing Address - Phone:503-872-4080
Mailing Address - Fax:503-872-0481
Practice Address - Street 1:9268 SE CLINTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1456
Practice Address - Country:US
Practice Address - Phone:503-872-4080
Practice Address - Fax:503-872-0481
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)