Healthcare Provider Details

I. General information

NPI: 1558290585
Provider Name (Legal Business Name): KATELYN GRACE JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: INDIGO JOHNSON

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 E TANQUE VERDE RD STE 210
TUCSON AZ
85715-3859
US

IV. Provider business mailing address

1942 S LILLIAN CIR
TUCSON AZ
85713-2601
US

V. Phone/Fax

Practice location:
  • Phone: 520-896-1400
  • Fax:
Mailing address:
  • Phone: 678-266-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-23568
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: