Provider Demographics
NPI:1740801836
Name:JOHANSON, LAURA (MA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CROSBY ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-2636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 DOCK ST
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-2733
Practice Address - Country:US
Practice Address - Phone:914-965-1109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285628552OtherANDRUS