Provider Demographics
NPI:1518761816
Name:JOHNSON, ANGELIS VANITY
Entity type:Individual
Prefix:
First Name:ANGELIS
Middle Name:VANITY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELIS
Other - Middle Name:VANITY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:50 RIDGEFIELD AVE UNIT 211
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-3105
Mailing Address - Country:US
Mailing Address - Phone:203-892-7392
Mailing Address - Fax:203-361-0134
Practice Address - Street 1:1000 BRIDGEPORT AVENUE
Practice Address - Street 2:211
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-993-6592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1262659106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty