Provider Demographics
NPI:1689079113
Name:HENRY, WILLIE ALTON SR
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:ALTON
Last Name:HENRY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2733
Mailing Address - Country:US
Mailing Address - Phone:617-479-0102
Mailing Address - Fax:617-479-0427
Practice Address - Street 1:180 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2733
Practice Address - Country:US
Practice Address - Phone:617-479-0102
Practice Address - Fax:617-479-0427
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)