Provider Demographics
NPI:1679173975
Name:HENRY, REQUEL JASMINE
Entity Type:Individual
Prefix:
First Name:REQUEL
Middle Name:JASMINE
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CEDAR HILL STREET SUITE 200
Mailing Address - Street 2:
Mailing Address - City:MALBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL STREET SUITE 200
Practice Address - Street 2:
Practice Address - City:MALBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01751
Practice Address - Country:US
Practice Address - Phone:708-846-1988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician