Basic Information
| Provider Information | |||||||||
| NPI: | 1720750920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | KEITH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2019 HEWITT DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770184028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085709299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6021 FAIRMONT PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775054511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817692238 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3258 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | 3258 | TX | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101Y00000X | 3258 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.