Provider Demographics
NPI:1114711918
Name:HENRY, LYNESA JANAI
Entity type:Individual
Prefix:
First Name:LYNESA
Middle Name:JANAI
Last Name:HENRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-1604
Mailing Address - Country:US
Mailing Address - Phone:314-354-4362
Mailing Address - Fax:
Practice Address - Street 1:9374 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3267
Practice Address - Country:US
Practice Address - Phone:314-932-2402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician