Provider Demographics
NPI:1316734502
Name:HENRY, AUDREY LAROSA (LMSW)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:LAROSA
Last Name:HENRY
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:AUDREY
Other - Middle Name:LAROSA
Other - Last Name:BARTRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AUDREY LAROSA WILSON
Mailing Address - Street 1:4323 COLDEN ST APT 10A
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5913
Mailing Address - Country:US
Mailing Address - Phone:347-606-6558
Mailing Address - Fax:
Practice Address - Street 1:799 E GUN HILL RD FL 1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6107
Practice Address - Country:US
Practice Address - Phone:718-471-0200
Practice Address - Fax:929-535-7576
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086613261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center