Basic Information
| Provider Information | |||||||||
| NPI: | 1023459716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CAMELLIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW,MSW,BA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REDWAY | ||||||||
| OtherFirstName: | CAMELLIA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCSW,MSW,BA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 PECK RD | ||||||||
| Address2: | TORRINGTON CLINICAL SERVICES BLDG 2 SUITE 2203 | ||||||||
| City: | TORRINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067906123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606267007 | ||||||||
| FaxNumber: | 8606267014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2013 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9336 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | OPTUM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-CONNECTICARE WELLMORE GRP/FACILITY | OTHER | 13671479 | 01 | CT | CAQH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | TORRINGTON D339230 | 01 | CT | BEACON HEALTH | OTHER | 008064941 | 05 | CT | MEDICAID | 060669107 | 01 | CT | UBH OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | MHN TRICARENORTH | OTHER |