Provider Demographics
NPI:1417262510
Name:JOHANSON, TED (MA)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4718
Mailing Address - Country:US
Mailing Address - Phone:860-343-5303
Mailing Address - Fax:860-344-3339
Practice Address - Street 1:681 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4718
Practice Address - Country:US
Practice Address - Phone:860-343-5303
Practice Address - Fax:860-344-3339
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health