Provider Demographics
NPI:1720236219
Name:JOHNSON, DERWIN
Entity Type:Individual
Prefix:
First Name:DERWIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 IRVING PL
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-2224
Mailing Address - Country:US
Mailing Address - Phone:516-208-8454
Mailing Address - Fax:
Practice Address - Street 1:380 NASSAU RD
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1343
Practice Address - Country:US
Practice Address - Phone:516-623-7741
Practice Address - Fax:516-623-7775
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19272101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)