MEDICARE: MS. SHAMARA ANTOINETTE 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	101YM0800X	Mental Health Counselor	105396	TX
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	17417	TX
3	1041C0700X	Clinical Social Worker	105396	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	105396	OTHER	TX	SOCIAL WORK

General Provider Information

NPI Number	:	1295403764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAMARA ANTOINETTE HENRY

Provider Business Mailing Address
First Line	:	2112 SW H K DODGEN LOOP STE 183
Second Line	:	#1114
City	:	TEMPLE
State	:	TX
Zip	:	76504-7014
Country	:	US
Telephone Number	:	254-677-8815
Fax Number	:

Provider Business Practice Location Address
First Line	:	2112 SW H K DODGEN LOOP STE 183
Second Line	:
City	:	TEMPLE
State	:	TX
Zip	:	76504-7014
Country	:	US
Telephone Number	:	254-677-8815
Fax Number	:

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

Provider Enumeration Date	:	08/31/2021
Last Update Date	:	06/09/2026

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