Provider Demographics
NPI:1205203924
Name:JOHNSON, DOROTHY MAE (BSL)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 N 4TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-3832
Mailing Address - Country:US
Mailing Address - Phone:215-456-0743
Mailing Address - Fax:
Practice Address - Street 1:5039 N 4TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-3832
Practice Address - Country:US
Practice Address - Phone:215-456-0743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2018-03-20
Deactivation Date:2018-03-02
Deactivation Code:
Reactivation Date:2018-03-20
Provider Licenses
StateLicense IDTaxonomies
PABH002783101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health