Provider Demographics
NPI:1386315059
Name:JOHNSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSON
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 1:1240 WALTON AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-8004
Mailing Address - Country:US
Mailing Address - Phone:646-899-5481
Mailing Address - Fax:
Practice Address - Street 1:1240 WALTON AVE APT 205
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-8004
Practice Address - Country:US
Practice Address - Phone:646-899-5481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health