Provider Demographics
NPI:1962278960
Name:ALEXANDRE, WIDNER (LADC I)
Entity type:Individual
Prefix:MR
First Name:WIDNER
Middle Name:
Last Name:ALEXANDRE
Suffix:
Gender:M
Credentials:LADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1403
Mailing Address - Country:US
Mailing Address - Phone:857-236-8190
Mailing Address - Fax:
Practice Address - Street 1:263 EUSTIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-2826
Practice Address - Country:US
Practice Address - Phone:617-445-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23160101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)