1023459716 NPI number — CAMELLIA A JOHNSON LCSW,MSW,BA

Table of content: CAMELLIA A JOHNSON LCSW,MSW,BA (NPI 1023459716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023459716 NPI number — CAMELLIA A JOHNSON LCSW,MSW,BA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
CAMELLIA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW,MSW,BA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REDWAY
Provider Other First Name:
CAMELLIA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW,MSW,BA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023459716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 E MAIN ST
Provider Second Line Business Mailing Address:
4TH FLOOR ADMINISTRATION
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06702-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-574-9000
Provider Business Mailing Address Fax Number:
203-574-9006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 PECK RD
Provider Second Line Business Practice Location Address:
TORRINGTON CLINICAL SERVICES BLDG 2 SUITE 2203
Provider Business Practice Location Address City Name:
TORRINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06790-6123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-626-7007
Provider Business Practice Location Address Fax Number:
860-626-7014
Provider Enumeration Date:
07/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  9336 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060669107 . This is a "OPTUM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-CONNECTICARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13671479 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "ANTHEM BCBS OF CT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "MHN MANAGED HEALTH NETWORK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "HEALTHYCT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "AETNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: TORRINGTON D339230 . This is a "BEACON HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008064941 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060669107 . This is a "UBH OXFORD HEALTH LIBERTY/FREEDOM WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "MHN TRICARENORTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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