Provider Demographics
NPI:1053127126
Name:HENRY, CONNOR ROBERT (LICSW)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:ROBERT
Last Name:HENRY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 MASSACHUSETTS AVE APT 508
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-4803
Mailing Address - Country:US
Mailing Address - Phone:860-818-1029
Mailing Address - Fax:
Practice Address - Street 1:175 DERBT STREET SUITE 21
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043
Practice Address - Country:US
Practice Address - Phone:781-424-8119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW11201431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical