Provider Demographics
NPI:1215211487
Name:ANDERSON, JOHANNA H (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:H
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JOHANNA
Other - Middle Name:H
Other - Last Name:NOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:1577 CONGRESS ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2169
Practice Address - Country:US
Practice Address - Phone:207-662-1442
Practice Address - Fax:207-775-2467
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC142291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400170444Medicare PIN
MEE400115151Medicare PIN