Provider Demographics
NPI:1740319300
Name:JOHANNESEN, INGRID (LCSW-R)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:JOHANNESEN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 STUART AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-4225
Mailing Address - Country:US
Mailing Address - Phone:631-598-0003
Mailing Address - Fax:631-598-0003
Practice Address - Street 1:55 STUART AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-4225
Practice Address - Country:US
Practice Address - Phone:631-598-0003
Practice Address - Fax:631-598-0003
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0486071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1635984OtherOXFORD
NYNF0571Medicare ID - Type Unspecified