Provider Demographics
NPI:1760909352
Name:JOHNSON, SHAUNTE NICOLE (MS)
Entity Type:Individual
Prefix:MS
First Name:SHAUNTE
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CHAMBERS ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2910
Mailing Address - Country:US
Mailing Address - Phone:860-463-0659
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE ST STE 325
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2215
Practice Address - Country:US
Practice Address - Phone:413-737-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor