Healthcare Provider Details

I. General information

NPI: 1528753811
Provider Name (Legal Business Name): AMY JOHNSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY JENSEN

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 US OVAL STE 100
PLATTSBURGH NY
12903-5901
US

IV. Provider business mailing address

22 US OVAL STE 100
PLATTSBURGH NY
12903-5901
US

V. Phone/Fax

Practice location:
  • Phone: 518-563-8206
  • Fax:
Mailing address:
  • Phone: 518-563-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number098155
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0135011
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: