Provider Demographics
NPI:1114197134
Name:JOHNSEN, JUDITH A (MSW)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MAIN ST STE 9
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2539
Mailing Address - Country:US
Mailing Address - Phone:631-563-5069
Mailing Address - Fax:
Practice Address - Street 1:153 MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2539
Practice Address - Country:US
Practice Address - Phone:631-563-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO33188-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical