Provider Demographics
NPI:1407620966
Name:JOHNSEN, EMMA ELIZABETH (LMSW)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:ELIZABETH
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 OLD STUMP RD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9689
Mailing Address - Country:US
Mailing Address - Phone:631-566-7395
Mailing Address - Fax:
Practice Address - Street 1:468 MAIN ST
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-3407
Practice Address - Country:US
Practice Address - Phone:631-772-6219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121597-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker