Basic Information
| Provider Information | |||||||||
| NPI: | 1598797235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | NOREEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 CHELSEA LANE | ||||||||
| Address2: | 319 FOXCROFT VILLAGE | ||||||||
| City: | LOCH SHELDRAKE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454366390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 COMMUNITY LANE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127540716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452928770 | ||||||||
| FaxNumber: | 8452924206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 0663571 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 072767 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00398370 | 05 | NY | MEDICAID |