Provider Demographics
NPI:1962139857
Name:HENSON, BREEANNA
Entity type:Individual
Prefix:
First Name:BREEANNA
Middle Name:
Last Name:HENSON
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 1:444 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1406
Mailing Address - Country:US
Mailing Address - Phone:618-450-0002
Mailing Address - Fax:
Practice Address - Street 1:1035 SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-1060
Practice Address - Country:US
Practice Address - Phone:217-532-6994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist