Healthcare Provider Details

I. General information

NPI: 1356026819
Provider Name (Legal Business Name): KEONI K HENSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 E BARNACLE AVE
APACHE JUNCTION AZ
85119-3796
US

IV. Provider business mailing address

588 CARSON PASS CT
SPARKS NV
89436-1877
US

V. Phone/Fax

Practice location:
  • Phone: 775-412-2351
  • Fax:
Mailing address:
  • Phone: 775-412-2351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: