Basic Information
| Provider Information | |||||||||
| NPI: | 1912544131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENLEY | ||||||||
| FirstName: | QUENTIN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6216 S LEWIS AVE STE 180 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189607407 | ||||||||
| FaxNumber: | 5396645738 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 N HARVARD AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741153140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185087135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2019 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1047 | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.