Basic Information
| Provider Information | |||||||||
| NPI: | 1528239399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CLARK | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 WEST ST | ||||||||
| Address2: | SUITE 29F | ||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034312455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033571180 | ||||||||
| FaxNumber: | 6033571185 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 WEST ST | ||||||||
| Address2: | SUITE 29F | ||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034312455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033571180 | ||||||||
| FaxNumber: | 6033571185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2008 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 0029 | NH | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 100-0000013 | VT | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 30426647 | 05 | NH | MEDICAID |