Provider Demographics
NPI:1710009444
Name:JOHNSON, ALEXIS ARLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:ARLEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 BOUTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-1426
Mailing Address - Country:US
Mailing Address - Phone:914-763-3201
Mailing Address - Fax:
Practice Address - Street 1:96 BOUTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH SALEM
Practice Address - State:NY
Practice Address - Zip Code:10590-1426
Practice Address - Country:US
Practice Address - Phone:914-763-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5359103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV53401Medicare ID - Type UnspecifiedPROVIDER ID