MEDICARE: DIANE MILLER 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	R026438-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0051430	OTHER	NY	GHI
2	P2781814	OTHER	NY	OXFORD
3	7708481	OTHER	NY	AETNA
4	AA73458	OTHER	NY	MDNY
5	145905	OTHER	NY	VALUE OPTIONS
6	24294	OTHER	NY	VYTRA

General Provider Information

NPI Number	:	1760570782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MILLER JOHNSON LCSW

Provider Business Mailing Address
First Line	:	970 GREENWAY E
Second Line	:
City	:	ORIENT
State	:	NY
Zip	:	11957-1314
Country	:	US
Telephone Number	:	631-323-1333
Fax Number	:	631-467-0080

Provider Business Practice Location Address
First Line	:	233 UNION AVE
Second Line	:	SUITE 202
City	:	HOLBROOK
State	:	NY
Zip	:	11741-1820
Country	:	US
Telephone Number	:	631-323-1333
Fax Number	:	631-467-0080

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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