Healthcare Provider Details

I. General information

NPI: 1922491463
Provider Name (Legal Business Name): DONNA JOHANSON LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SPRING LAKE RD
SHERMAN CT
06784-1200
US

IV. Provider business mailing address

40 SPRING LAKE RD
SHERMAN CT
06784-1200
US

V. Phone/Fax

Practice location:
  • Phone: 860-729-4631
  • Fax: 888-972-5017
Mailing address:
  • Phone: 860-729-4631
  • Fax: 888-972-5017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number008353
License Number StateCT

VIII. Authorized Official

Name: DONNA JOHANSON
Title or Position: PROVIDER
Credential: LCSW
Phone: 860-729-4631