Healthcare Provider Details

I. General information

NPI: 1376765768
Provider Name (Legal Business Name): PAMELA DIANNE JOHNSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 MADISON AVE E
MAGNOLIA NJ
08049-1409
US

IV. Provider business mailing address

212 MADISON AVE E
MAGNOLIA NJ
08049-1409
US

V. Phone/Fax

Practice location:
  • Phone: 856-541-1700
  • Fax: 856-309-9716
Mailing address:
  • Phone: 856-541-1700
  • Fax: 856-309-9716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW005730E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: