Basic Information
| Provider Information | |||||||||
| NPI: | 1710410618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4419 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183647700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4419 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183647700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/22/2017 | ||||||||
| NPIReactivationDate: | 12/27/2017 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 091799 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 093288-1 | NY | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.