Provider Demographics
NPI:1982621462
Name:BROUGHTON, JOHANNA LYNNE (LICSW LADC)
Entity Type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:LYNNE
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:LICSW LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MIRONA ROAD EXTENSION
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801
Mailing Address - Country:US
Mailing Address - Phone:603-436-7959
Mailing Address - Fax:603-766-3141
Practice Address - Street 1:30 MIRONA ROAD EXTENSION
Practice Address - Street 2:SUITE 3
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-664-1010
Practice Address - Fax:603-766-3141
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH513101YA0400X
NH1006104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
115858OtherMMC PHO BHC P
NH30423349Medicaid
117879OtherBHN