Healthcare Provider Details

I. General information

NPI: 1710009444
Provider Name (Legal Business Name): ALEXIS ARLEEN JOHNSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 BOUTON RD
SOUTH SALEM NY
10590-1426
US

IV. Provider business mailing address

96 BOUTON RD
SOUTH SALEM NY
10590-1426
US

V. Phone/Fax

Practice location:
  • Phone: 914-763-3201
  • Fax:
Mailing address:
  • Phone: 914-763-3201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5359
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: