Provider Demographics
NPI:1043053028
Name:HENECKE, KAITLYN ANNE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ANNE
Last Name:HENECKE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4579 SOUZA CT
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-1259
Mailing Address - Country:US
Mailing Address - Phone:208-317-5480
Mailing Address - Fax:
Practice Address - Street 1:2222 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2475
Practice Address - Country:US
Practice Address - Phone:541-224-6987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician