Provider Demographics
NPI:1992683593
Name:JOHNSON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1408
Mailing Address - Country:US
Mailing Address - Phone:914-396-8200
Mailing Address - Fax:
Practice Address - Street 1:220 HEBERTON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1415
Practice Address - Country:US
Practice Address - Phone:718-448-1900
Practice Address - Fax:718-448-1903
Is Sole Proprietor?:No
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)