Provider Demographics
NPI:1952147761
Name:TOBON, JOHANNA KATHERINE
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:KATHERINE
Last Name:TOBON
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 1:420 FRUIT HILL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02911-2626
Mailing Address - Country:US
Mailing Address - Phone:401-543-6269
Mailing Address - Fax:
Practice Address - Street 1:164 CHAPLIN ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02861-1748
Practice Address - Country:US
Practice Address - Phone:401-543-6269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW228967101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health