Basic Information
| Provider Information | |||||||||
| NPI: | 1558832436 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY-RENNIE | ||||||||
| FirstName: | AFEISHA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 DUDLEY ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021192769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179899499 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 520 DUDLEY ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021192769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179899499 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0 | 01 | MA | 0 | OTHER |