Basic Information
| Provider Information | |||||||||
| NPI: | 1316581457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ELLA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4325 HUNTER ST APT 643E | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111014465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623285573 | ||||||||
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| Practice Location | |||||||||
| Address1: | 230 W 17TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100115325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122065200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 107715 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.