Healthcare Provider Details

I. General information

NPI: 1700902103
Provider Name (Legal Business Name): STEPHANIE ANN JOHNSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OCEAN AVE
REVERE MA
02151-3675
US

IV. Provider business mailing address

200 LEISURE LN APARTMENT #80
STONEHAM MA
02180-4003
US

V. Phone/Fax

Practice location:
  • Phone: 781-485-6100
  • Fax:
Mailing address:
  • Phone: 781-724-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number112048
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: