Provider Demographics
NPI:1770684458
Name:HENRY, CHARLES ALFRED (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALFRED
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 BROOKLINE PLACE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445
Mailing Address - Country:US
Mailing Address - Phone:617-278-0272
Mailing Address - Fax:617-278-2120
Practice Address - Street 1:1 BROOKLINE PLACE
Practice Address - Street 2:SUITE 502
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445
Practice Address - Country:US
Practice Address - Phone:617-278-0272
Practice Address - Fax:617-278-2120
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1544582084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3191176Medicaid
MA110060905Medicaid
MA3191176Medicaid