Healthcare Provider Details

I. General information

NPI: 1861893984
Provider Name (Legal Business Name): SCOTT ANDREW JOHNSON LMSW, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 WILLIAM FLOYD PKWY
SHIRLEY NY
11967-1809
US

IV. Provider business mailing address

433 OCEAN AVE
OAKDALE NY
11769-1508
US

V. Phone/Fax

Practice location:
  • Phone: 631-655-4246
  • Fax:
Mailing address:
  • Phone: 631-655-4246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number092904
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: