Provider Demographics
NPI:1962794552
Name:JOHANESEN, JOAN (MSW, PHD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:JOHANESEN
Suffix:
Gender:F
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4485 ELLIOT AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6416
Mailing Address - Country:US
Mailing Address - Phone:321-225-9315
Mailing Address - Fax:
Practice Address - Street 1:4485 ELLIOT AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6416
Practice Address - Country:US
Practice Address - Phone:321-225-9315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW21491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical