Provider Demographics
NPI:1700902103
Name:JOHNSON, STEPHANIE ANN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LEISURE LN
Mailing Address - Street 2:APARTMENT #80
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-4003
Mailing Address - Country:US
Mailing Address - Phone:781-724-4275
Mailing Address - Fax:
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3675
Practice Address - Country:US
Practice Address - Phone:781-485-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1120481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical