Provider Demographics
NPI:1336964493
Name:JOHANSEN, ISA (LAC)
Entity type:Individual
Prefix:
First Name:ISA
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BROADVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-2819
Mailing Address - Country:US
Mailing Address - Phone:862-204-9636
Mailing Address - Fax:
Practice Address - Street 1:242 OLD NEW BRUNSWICK RD STE 150
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-3750
Practice Address - Country:US
Practice Address - Phone:856-354-0664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00821200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health