Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 35SI00308600 | NJ |
NPI | 1124130513 |
---|---|
Provider Name | Ms. Lynnette Johnson |
First Address | South Orange, NJ 07079-2435 |
Second Address | East Orange, NJ 07018-1023 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |