Healthcare Provider Details

I. General information

NPI: 1710410618
Provider Name (Legal Business Name): SAMANTHA JOHNSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date: 11/22/2017
Reactivation Date: 12/27/2017

III. Provider practice location address

4419 3RD AVE
BRONX NY
10457-2562
US

IV. Provider business mailing address

4419 3RD AVE
BRONX NY
10457-2562
US

V. Phone/Fax

Practice location:
  • Phone: 718-364-7700
  • Fax:
Mailing address:
  • Phone: 718-364-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091799
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number093288-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: