Healthcare Provider Details

I. General information

NPI: 1528332228
Provider Name (Legal Business Name): ELIZABETH JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE MAIL STOP 116B
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE MAIL STOP 116B
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-5695
  • Fax: 857-364-4408
Mailing address:
  • Phone: 857-364-5695
  • Fax: 857-364-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01272
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPS01272
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: