Basic Information
| Provider Information | |||||||||
| NPI: | 1891955274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DEANA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPAGNOLETTI JOHNSON | ||||||||
| OtherFirstName: | DEANA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1220 DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532132504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546539 | ||||||||
| FaxNumber: | 4144546688 | ||||||||
| Practice Location | |||||||||
| Address1: | 8901 W LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532272409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143295657 | ||||||||
| FaxNumber: | 4143295637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 178005118 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | 2920 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0004X | 2920 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Health | 101YP2500X | 4085 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 43744000 | 05 | WI | MEDICAID |