Provider Demographics
NPI:1639473671
Name:JOHNSON, TASHA MONIQUE
Entity Type:Individual
Prefix:MS
First Name:TASHA
Middle Name:MONIQUE
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 1:1 SUNSET TERR.
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111
Mailing Address - Country:US
Mailing Address - Phone:973-477-4435
Mailing Address - Fax:
Practice Address - Street 1:1 SUNSET TERR.
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111
Practice Address - Country:US
Practice Address - Phone:973-477-4435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ509815103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities