MEDICARE: LAKEISHA DANIELLE HENRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904014204	VA

General Provider Information

NPI Number	:	1104535095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEISHA DANIELLE HENRY

Provider Business Mailing Address
First Line	:	4505 BILTMORE DR NW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24017-1513
Country	:	US
Telephone Number	:	540-491-1552
Fax Number	:

Provider Business Practice Location Address
First Line	:	4505 BILTMORE DR NW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24017-1513
Country	:	US
Telephone Number	:	540-491-1552
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2022
Last Update Date	:	11/18/2022

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