Provider Demographics
NPI:1902690803
Name:JOHNSON, ELISSA
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 THE GRN STE B
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3618
Mailing Address - Country:US
Mailing Address - Phone:832-562-8461
Mailing Address - Fax:
Practice Address - Street 1:8 THE GRN STE B
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3618
Practice Address - Country:US
Practice Address - Phone:832-562-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician