Provider Demographics
NPI:1568219772
Name:JOHANESSON, THOMAS RAY (MSW, LSW)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RAY
Last Name:JOHANESSON
Suffix:
Gender:
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 N OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-2157
Mailing Address - Country:US
Mailing Address - Phone:917-232-0389
Mailing Address - Fax:
Practice Address - Street 1:1901 N OLDEN AVENUE EXT STE 29
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08618-2111
Practice Address - Country:US
Practice Address - Phone:609-237-7100
Practice Address - Fax:609-616-7904
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ018447161041S0200X
NJ44SL07188400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool