Provider Demographics
NPI:1033292164
Name:JOHNSON, NANCY E (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:KETELTAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:520 FRANKLIN AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:516-753-4447
Mailing Address - Fax:516-753-4447
Practice Address - Street 1:520 FRANKLIN AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-753-4447
Practice Address - Fax:516-753-4447
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04334911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
181333OtherMHN
P4042822OtherMULTIPLAN
143440OtherVALUE OPTIONS
0433491OtherHIP
O1872501OtherOXFORD
0433491OtherHIP