Provider Demographics
NPI:1760570782
Name:JOHNSON, DIANE MILLER (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MILLER
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 GREENWAY E
Mailing Address - Street 2:
Mailing Address - City:ORIENT
Mailing Address - State:NY
Mailing Address - Zip Code:11957-1314
Mailing Address - Country:US
Mailing Address - Phone:631-323-1333
Mailing Address - Fax:631-467-0080
Practice Address - Street 1:233 UNION AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1820
Practice Address - Country:US
Practice Address - Phone:631-323-1333
Practice Address - Fax:631-467-0080
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR026438-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0051430OtherGHI
NYP2781814OtherOXFORD
NY7708481OtherAETNA
NYAA73458OtherMDNY
NY145905OtherVALUE OPTIONS
NY24294OtherVYTRA
NY145905OtherVALUE OPTIONS