Provider Demographics
NPI:1578607099
Name:JOHANSEN, CAROLYN SUZANNE (RD, CDE, CD)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:SUZANNE
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:RD, CDE, CD
Other - Prefix:MRS
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:JOHANSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, CDE, CD
Mailing Address - Street 1:19 WINDRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05676-9135
Mailing Address - Country:US
Mailing Address - Phone:802-244-4122
Mailing Address - Fax:802-244-4122
Practice Address - Street 1:20 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-4826
Practice Address - Country:US
Practice Address - Phone:802-476-7607
Practice Address - Fax:802-244-4122
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074-0000070133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007165Medicaid
VT47689OtherMVP NUMBER
VT28597OtherBLUE CROSS BLUE SHIELD NU
VTGREE 29429OtherBCBS GREEN MT NUTRITRION
VTGREE 29429OtherBCBS GREEN MT NUTRITRION
VTJOMTO132Medicare ID - Type UnspecifiedMY MEDICARE NUMBER