Healthcare Provider Details

I. General information

NPI: 1851256044
Provider Name (Legal Business Name): DMITRI HENRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 LAVACA ST
AUSTIN TX
78701-1634
US

IV. Provider business mailing address

1401 LAVACA ST
AUSTIN TX
78701-1634
US

V. Phone/Fax

Practice location:
  • Phone: 404-404-8457
  • Fax:
Mailing address:
  • Phone: 404-404-8457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number5743433
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: