MEDICARE: MRS. ELIZABETH ANN HENLEY

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	385HR2055X	Child Mental Illness Respite Care	623357	AZ

General Provider Information

NPI Number	:	1336306661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH ANN HENLEY

Provider Business Mailing Address
First Line	:	2755 S 4TH AVE
Second Line	:	BLDG 3 STE104
City	:	YUMA
State	:	AZ
Zip	:	85364-7236
Country	:	US
Telephone Number	:	928-329-9313
Fax Number	:	928-329-9719

Provider Business Practice Location Address
First Line	:	2755 S 4TH AVE
Second Line	:	BLDG 3 STE 104
City	:	YUMA
State	:	AZ
Zip	:	85364-7236
Country	:	US
Telephone Number	:	928-329-9313
Fax Number	:	928-329-9719

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

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	05/22/2008

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