Healthcare Provider Details

I. General information

NPI: 1750863817
Provider Name (Legal Business Name): ANGELA A. JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5229 MILL WAY
STONE MOUNTAIN GA
30083-1641
US

IV. Provider business mailing address

5229 MILL WAY
STONE MOUNTAIN GA
30083-1641
US

V. Phone/Fax

Practice location:
  • Phone: 317-698-2594
  • Fax:
Mailing address:
  • Phone: 317-698-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09932503
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149027874
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06929300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW009045
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: