Provider Demographics
NPI:1669862058
Name:JOHNSON, JOETTE MELISSA
Entity Type:Individual
Prefix:MS
First Name:JOETTE
Middle Name:MELISSA
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 1:645 FARMINGTON AVENUE
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-578-9179
Mailing Address - Fax:860-760-6129
Practice Address - Street 1:645 FARMINGTON AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2907
Practice Address - Country:US
Practice Address - Phone:860-578-9179
Practice Address - Fax:860-760-6129
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2021-10-07
Deactivation Date:2019-03-21
Deactivation Code:
Reactivation Date:2021-10-07
Provider Licenses
StateLicense IDTaxonomies
CT0087321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical