MEDICARE: MR. THOMAS RAY JOHANESSON MSW, LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker	01844716	NJ
2	104100000X	Social Worker	44SL07188400	NJ

General Provider Information

NPI Number	:	1568219772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS RAY JOHANESSON MSW, LSW

Provider Business Mailing Address
First Line	:	1307 N OAKS BLVD
Second Line	:
City	:	NORTH BRUNSWICK
State	:	NJ
Zip	:	08902-2157
Country	:	US
Telephone Number	:	917-232-0389
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 N OAKS BLVD
Second Line	:
City	:	NORTH BRUNSWICK
State	:	NJ
Zip	:	08902-2157
Country	:	US
Telephone Number	:	917-232-0389
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2024
Last Update Date	:	06/05/2026

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