Provider Demographics
NPI:1518340538
Name:JOHNSON, ELISE LILLIAN (MSW, LSW)
Entity Type:Individual
Prefix:MS
First Name:ELISE
Middle Name:LILLIAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 S ALDEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-5515
Mailing Address - Country:US
Mailing Address - Phone:646-546-0695
Mailing Address - Fax:
Practice Address - Street 1:1798 W HUNTING PARK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-3408
Practice Address - Country:US
Practice Address - Phone:215-227-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06045100104100000X
PASW1315001041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker