Healthcare Provider Details

I. General information

NPI: 1013645779
Provider Name (Legal Business Name): KLONETTE JOHNSON EDD,LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 STEUBEN ST
STATEN ISLAND NY
10304-3370
US

IV. Provider business mailing address

231 STEUBEN ST
STATEN ISLAND NY
10304-3370
US

V. Phone/Fax

Practice location:
  • Phone: 929-877-8008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number116730
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: