Provider Demographics
NPI:1164512505
Name:JOHNSON, STACIA OAKES (MSW)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:OAKES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ESSEX SQ
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1141
Mailing Address - Country:US
Mailing Address - Phone:860-767-1887
Mailing Address - Fax:860-526-3650
Practice Address - Street 1:1 ESSEX SQ
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1141
Practice Address - Country:US
Practice Address - Phone:860-767-1887
Practice Address - Fax:860-526-3650
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0049421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical