Provider Demographics
NPI:1952379331
Name:JOHNSON, SUSAN T (MS LICSW BCD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS LICSW BCD
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:W
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS IN SOCIAL WORK
Mailing Address - Street 1:61 GOLDENCREST AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1318
Mailing Address - Country:US
Mailing Address - Phone:617-803-5750
Mailing Address - Fax:781-290-0130
Practice Address - Street 1:61 GOLDENCREST AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1318
Practice Address - Country:US
Practice Address - Phone:617-803-5750
Practice Address - Fax:781-290-0130
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1031251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
J0PC1463Medicare ID - Type Unspecified
MAPO1463Medicare PIN