Basic Information
| Provider Information | |||||||||
| NPI: | 1972114411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DORIS | ||||||||
| MiddleName: | OSIIMWE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | COUNSELOR- HUMAN SE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 52 ELAINE CIR # 52 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011091205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813301507 | ||||||||
| FaxNumber: | 6176004728 | ||||||||
| Practice Location | |||||||||
| Address1: | 52 ELAINE CIR # 52 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011091205 | ||||||||
| CountryCode: | US | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2020 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 001451295 | 01 | MA | COUNSELOR | OTHER |