MEDICARE: MARIA G JOHNSON LCSW

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	080480	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080480	OTHER	NY	LICENSED CLINICAL SOCIAL WORKER
2	8118596	OTHER	NY	REGISTERED LICENSED CLINICAL SOCIAL WORKER

General Provider Information

NPI Number	:	1326482845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA G JOHNSON LCSW

Provider Business Mailing Address
First Line	:	671 BAUER CT
Second Line	:
City	:	ELMONT
State	:	NY
Zip	:	11003-4312
Country	:	US
Telephone Number	:	516-451-1258
Fax Number	:	516-285-1616

Provider Business Practice Location Address
First Line	:	430 W MERRICK RD
Second Line	:	SUITE 25
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-5201
Country	:	US
Telephone Number	:	516-451-1258
Fax Number	:	516-285-1616

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

Provider Enumeration Date	:	04/26/2013
Last Update Date	:	11/13/2014

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