Healthcare Provider Details

I. General information

NPI: 1124130513
Provider Name (Legal Business Name): LYNNETTE JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 TREMONT AVE 116F
EAST ORANGE NJ
07018-1023
US

IV. Provider business mailing address

556 IRVING TER
SOUTH ORANGE NJ
07079-2435
US

V. Phone/Fax

Practice location:
  • Phone: 973-676-1000
  • Fax: 973-395-7016
Mailing address:
  • Phone: 973-763-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number35SI00308600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: