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General NPI Number Information
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NPI Number | 1699287771
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Entity Type | Individual
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Provider Name | KEISHA MARIE HENRY WLS, CWC
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Gender | Male
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Dates
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Enumeration Date | 10/30/2017
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Last Update Date | 10/30/2017
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Provider Practice Location Address
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Address Line | 3330 CUMBERLAND BLVD SE STE 500
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City | ATLANTA
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State | GA
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Zip | 30339-5997
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Country | US
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Telephone | 678-242-9239
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Fax | 770-933-6223
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Provider Business Mailing Address
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Address Line | 1309 ADCOX SQ
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City | STONE MOUNTAIN
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State | GA
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Zip | 30088-4544
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Country | US
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Telephone | 321-460-9429
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State | GA
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