Basic Information
| Provider Information | |||||||||
| NPI: | 1790933489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STREETER JOHNSON | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STREETER | ||||||||
| OtherFirstName: | REGINA | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13028 176TH PL | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114345850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184984100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 796H DREW ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112084704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182353100 | ||||||||
| FaxNumber: | 7182770822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2008 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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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 | 0707331 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.