=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295141182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA MARIE JOHNSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2014
-----------------------------------------------------
Last Update Date | 02/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 LASALLE AVE # 108
-----------------------------------------------------
City | KENMORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14217-2641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-510-7475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 LASALLE AVE 108
-----------------------------------------------------
City | KENMORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14217-2641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-510-7475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 078973-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------