MEDICARE: CONSTANCE JOHANNESSEN PSY, D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	NH718	NH

General Provider Information

NPI Number	:	1194840249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONSTANCE JOHANNESSEN PSY, D.

Provider Business Mailing Address
First Line	:	155 LAFAYETTE RD
Second Line	:	SUITE 3
City	:	NORTH HAMPTON
State	:	NH
Zip	:	03862-2464
Country	:	US
Telephone Number	:	603-964-4869
Fax Number	:	603-964-4980

Provider Business Practice Location Address
First Line	:	155 LAFAYETTE RD
Second Line	:	SUITE 3
City	:	NORTH HAMPTON
State	:	NH
Zip	:	03862-2464
Country	:	US
Telephone Number	:	603-964-4869
Fax Number	:	603-964-4980

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	03/25/2010

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