Provider Demographics
NPI:1609939966
Name:JOHNSON, PETER L (LICSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WARE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1540
Mailing Address - Country:US
Mailing Address - Phone:617-628-3535
Mailing Address - Fax:617-628-5222
Practice Address - Street 1:39 WARE ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1540
Practice Address - Country:US
Practice Address - Phone:617-628-3535
Practice Address - Fax:617-628-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10231561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPP0323OtherBLUECROSSBLUESHIELD
MA384903OtherPRIVATEHEALTHCARESYSTEMS
MA081944OtherVALUEOPTIONS
MA1062677OtherFIRSTHEALTH
MAA017539OtherHARVARD PILGRIM
MAPO6669Medicare ID - Type UnspecifiedLICSW