Healthcare Provider Details

I. General information

NPI: 1770684458
Provider Name (Legal Business Name): CHARLES ALFRED HENRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKLINE PLACE SUITE 502
BROOKLINE MA
02445
US

IV. Provider business mailing address

1 BROOKLINE PLACE SUITE 502
BROOKLINE MA
02445
US

V. Phone/Fax

Practice location:
  • Phone: 617-278-0272
  • Fax: 617-278-2120
Mailing address:
  • Phone: 617-278-0272
  • Fax: 617-278-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number154458
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number154458
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3191176
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
Identifier110060905
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: