Healthcare Provider Details

I. General information

NPI: 1336234822
Provider Name (Legal Business Name): JUDITH L JOHNSON LCSW, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LOYOLA RD
ST AUGUSTINE FL
32086-6022
US

IV. Provider business mailing address

104 LOYOLA RD
ST AUGUSTINE FL
32086-6022
US

V. Phone/Fax

Practice location:
  • Phone: 573-803-7892
  • Fax: 904-797-2723
Mailing address:
  • Phone: 573-803-7892
  • Fax: 904-797-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11715
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: