Basic Information
| Provider Information | |||||||||
| NPI: | 1073684031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | WHILMA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CAPITAL WAY | ||||||||
| Address2: | PSYCHIATRY DEPARTMENT | ||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093946085 | ||||||||
| FaxNumber: | 6093946250 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CAPITAL WAY | ||||||||
| Address2: | PSYCHIATRY DEPT | ||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093946085 | ||||||||
| FaxNumber: | 6093946250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 25MA08608300 | NJ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | G60230 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD435312 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00G602300 | 05 | CA | MEDICAID | 0211362 | 05 | NJ | MEDICAID |