Provider Demographics
NPI:1972114411
Name:JOHNSON, DORIS OSIIMWE (COUNSELOR- HUMAN SE)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:OSIIMWE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COUNSELOR- HUMAN SE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 ELAINE CIR # 52
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-1205
Mailing Address - Country:US
Mailing Address - Phone:781-330-1507
Mailing Address - Fax:617-600-4728
Practice Address - Street 1:52 ELAINE CIR # 52
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-1205
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001451295OtherCOUNSELOR