Provider Demographics
NPI:1033751110
Name:JOHNSON, ZACHARY CARLTON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:CARLTON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202A E MAIN ST # A
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1857
Mailing Address - Country:US
Mailing Address - Phone:231-679-4685
Mailing Address - Fax:
Practice Address - Street 1:998 CROOKED HILL RD BLDG 5
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1019
Practice Address - Country:US
Practice Address - Phone:631-306-5775
Practice Address - Fax:718-210-3559
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107279-01104100000X
NY0945631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker