Provider Demographics
NPI:1861893984
Name:JOHNSON, SCOTT ANDREW (LMSW, PHD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANDREW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1508
Mailing Address - Country:US
Mailing Address - Phone:631-655-4246
Mailing Address - Fax:
Practice Address - Street 1:1250 WILLIAM FLOYD PKWY
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-1809
Practice Address - Country:US
Practice Address - Phone:631-655-4246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0929041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical