Provider Demographics
NPI:1891260022
Name:NGUYEN, JOHNNY (LICSW)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ROMSEY ST # 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1312
Mailing Address - Country:US
Mailing Address - Phone:617-259-6323
Mailing Address - Fax:
Practice Address - Street 1:21 ROMSEY ST # 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1312
Practice Address - Country:US
Practice Address - Phone:617-259-6323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1212161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical