Provider Demographics
NPI:1811776339
Name:THEODAT, JOHANNE
Entity type:Individual
Prefix:MS
First Name:JOHANNE
Middle Name:
Last Name:THEODAT
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 1:605 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-4114
Mailing Address - Country:US
Mailing Address - Phone:413-266-2202
Mailing Address - Fax:413-301-5164
Practice Address - Street 1:605 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-4114
Practice Address - Country:US
Practice Address - Phone:413-266-2202
Practice Address - Fax:413-301-5164
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker