Provider Demographics
NPI:1528753811
Name:JOHNSON, AMY (LICSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 US OVAL STE 100
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12903-5901
Mailing Address - Country:US
Mailing Address - Phone:518-563-8206
Mailing Address - Fax:
Practice Address - Street 1:22 US OVAL STE 100
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12903-5901
Practice Address - Country:US
Practice Address - Phone:518-563-8206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0981551041C0700X
VT089.01350111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical