Provider Demographics
NPI:1518558097
Name:JOHNSON, MYRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1364
Mailing Address - Country:US
Mailing Address - Phone:914-498-0844
Mailing Address - Fax:
Practice Address - Street 1:256 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10553-1052
Practice Address - Country:US
Practice Address - Phone:914-498-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health