Provider Demographics
NPI:1215336888
Name:HENRY, RAQUEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 BROADWAY STE 610
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2026
Mailing Address - Country:US
Mailing Address - Phone:510-628-9068
Mailing Address - Fax:
Practice Address - Street 1:1440 BROADWAY STE 610
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2026
Practice Address - Country:US
Practice Address - Phone:510-628-9068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2022-06-29
Deactivation Date:2022-05-10
Deactivation Code:
Reactivation Date:2022-06-08
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103T00000X
CA33320103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor