Provider Demographics
NPI:1265423396
Name:JOHNSON, JOAN SHARON
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:SHARON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05472-2003
Mailing Address - Country:US
Mailing Address - Phone:802-453-7912
Mailing Address - Fax:
Practice Address - Street 1:30 NORTH ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:VT
Practice Address - Zip Code:05472-2003
Practice Address - Country:US
Practice Address - Phone:802-453-7912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000272103T00000X
VT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007025Medicaid