Provider Demographics
NPI:1699287771
Name:HENRY, KEISHA MARIE (WLS, CWC)
Entity type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:MARIE
Last Name:HENRY
Suffix:
Gender:M
Credentials:WLS, CWC
Other - Prefix:MS
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WLS, CWC
Mailing Address - Street 1:1309 ADCOX SQ
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-4544
Mailing Address - Country:US
Mailing Address - Phone:321-460-9429
Mailing Address - Fax:
Practice Address - Street 1:3330 CUMBERLAND BLVD SE STE 500
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5997
Practice Address - Country:US
Practice Address - Phone:678-242-9239
Practice Address - Fax:770-933-6223
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization