Healthcare Provider Details

I. General information

NPI: 1770328627
Provider Name (Legal Business Name): MICHAEL DOUGLAS HENLEY JR. LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 INDEPENDENCE AVE
KENNETT MO
63857-1316
US

IV. Provider business mailing address

1226 INDEPENDENCE AVE
KENNETT MO
63857-1316
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-5925
  • Fax:
Mailing address:
  • Phone: 573-888-5925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2025038556
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: