Provider Demographics
NPI:1700368453
Name:JOHANNESSEN, JOANN
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:JOHANNESSEN
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 1:22 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-2054
Mailing Address - Country:US
Mailing Address - Phone:631-255-6312
Mailing Address - Fax:
Practice Address - Street 1:22 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-2054
Practice Address - Country:US
Practice Address - Phone:631-255-6312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency