Provider Demographics
NPI:1124130513
Name:JOHNSON, LYNNETTE (PHD)
Entity type:Individual
Prefix:MS
First Name:LYNNETTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 IRVING TER
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2435
Mailing Address - Country:US
Mailing Address - Phone:973-763-5701
Mailing Address - Fax:
Practice Address - Street 1:385 TREMONT AVE
Practice Address - Street 2:116F
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1023
Practice Address - Country:US
Practice Address - Phone:973-676-1000
Practice Address - Fax:973-395-7016
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00308600103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)