MEDICARE: MRS. LISA M JOHNSON-HOLLOWAY L.C.S.W.

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	1041C0700X	Clinical Social Worker	7326	CT

General Provider Information

NPI Number	:	1235459959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA M JOHNSON-HOLLOWAY L.C.S.W.

Provider Business Mailing Address
First Line	:	PO BOX 253
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-0253
Country	:	US
Telephone Number	:	860-243-3315
Fax Number	:	860-242-7811

Provider Business Practice Location Address
First Line	:	701 COTTAGE GROVE RD STE F120
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3095
Country	:	US
Telephone Number	:	860-243-3315
Fax Number	:	860-242-7811

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

Provider Enumeration Date	:	06/04/2010
Last Update Date	:	05/14/2017

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