Healthcare Provider Details

I. General information

NPI: 1396396305
Provider Name (Legal Business Name): MR. ALFONSO MACK HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 WELLS AVE
NEWTON MA
02459-3325
US

IV. Provider business mailing address

1612 WORCESTER RD APT 618A
FRAMINGHAM MA
01702-5480
US

V. Phone/Fax

Practice location:
  • Phone: 774-766-8780
  • Fax:
Mailing address:
  • Phone: 309-660-0134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number128637
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: