Provider Demographics
NPI:1699552141
Name:HENRY, GEORGIA
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ROLAND WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-2034
Mailing Address - Country:US
Mailing Address - Phone:510-746-2800
Mailing Address - Fax:510-746-2810
Practice Address - Street 1:250 EXECUTIVE PARK BLVD STE 4900
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-3335
Practice Address - Country:US
Practice Address - Phone:415-656-0116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143766106H00000X
101YM0800X, 171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker