Provider Demographics
NPI:1619179249
Name:JOHNSON, ANN (PHD)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 CAUSEWAY ST
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2900
Mailing Address - Country:US
Mailing Address - Phone:617-331-1762
Mailing Address - Fax:
Practice Address - Street 1:239 CAUSEWAY ST
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-2900
Practice Address - Country:US
Practice Address - Phone:617-331-1762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6979103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06278OtherBLUE SHIELD
MAW51185Medicare ID - Type Unspecified