Provider Demographics
NPI:1023805793
Name:JOHNSON, THERESA (AMF)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 VAUGHN ST
Mailing Address - Street 2:
Mailing Address - City:LUZERNE
Mailing Address - State:PA
Mailing Address - Zip Code:18709-1425
Mailing Address - Country:US
Mailing Address - Phone:570-301-0076
Mailing Address - Fax:
Practice Address - Street 1:335 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3808
Practice Address - Country:US
Practice Address - Phone:570-825-6425
Practice Address - Fax:570-762-9011
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAMF000059106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist