Basic Information
| Provider Information | |||||||||
| NPI: | 1770860744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | MICHAELA | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1745 BROADWAY FL 17 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100194642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518102 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Practice Location | |||||||||
| Address1: | 1745 BROADWAY FL 17 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100194642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518102 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 103T00000X | TN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 022145 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 04796681 | 05 | NY | MEDICAID |