Provider Demographics
NPI:1619738317
Name:JOHNSON, THERESA TARA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:TARA
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 1:1010 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2600
Mailing Address - Country:US
Mailing Address - Phone:617-534-4222
Mailing Address - Fax:857-288-2305
Practice Address - Street 1:25 JAMES ONEILL ST
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4504
Practice Address - Country:US
Practice Address - Phone:617-534-9500
Practice Address - Fax:617-419-1706
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)