Healthcare Provider Details

I. General information

NPI: 1235459959
Provider Name (Legal Business Name): LISA M JOHNSON-HOLLOWAY L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 05/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 COTTAGE GROVE RD STE F120
BLOOMFIELD CT
06002-3095
US

IV. Provider business mailing address

PO BOX 253
BLOOMFIELD CT
06002-0253
US

V. Phone/Fax

Practice location:
  • Phone: 860-243-3315
  • Fax: 860-242-7811
Mailing address:
  • Phone: 860-243-3315
  • Fax: 860-242-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7326
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: