=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386335453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSICA JOHNSON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2023
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 241 ROSENGARTEN DR
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06704-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-809-3317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 241 ROSENGARTEN DR
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06704-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-809-3317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150110750
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------