MEDICARE: AUDREY JANE 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1558127076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY JANE HENLEY

Provider Business Mailing Address
First Line	:	1910 1ST AVE S APT 21
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3748
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5215 EDINA INDUSTRIAL BLVD STE 200
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55439-2926
Country	:	US
Telephone Number	:	612-594-8405
Fax Number	:

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

Provider Enumeration Date	:	02/22/2024
Last Update Date	:	02/22/2024

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