Provider Demographics
NPI:1902636301
Name:HENESCH, MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:HENESCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KINGSLAND CT
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2747
Mailing Address - Country:US
Mailing Address - Phone:347-587-9672
Mailing Address - Fax:
Practice Address - Street 1:17-10 FAIR LAWN AVE FL 2
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2324
Practice Address - Country:US
Practice Address - Phone:201-794-7977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00731200152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist