Provider Demographics
NPI:1043876618
Name:JOHNSON, THOMAS SR (LPC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1401
Mailing Address - Country:US
Mailing Address - Phone:973-677-7053
Mailing Address - Fax:
Practice Address - Street 1:220 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1401
Practice Address - Country:US
Practice Address - Phone:973-677-7053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-19
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000623101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0314111Medicaid
NJ0314129Medicaid