Healthcare Provider Details

I. General information

NPI: 1811204373
Provider Name (Legal Business Name): JUDY A JOHNSON L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-5914 MAMALAHOA HWY
HOLUALOA HI
96725
US

IV. Provider business mailing address

PO BOX 752
HOLUALOA HI
96725-0752
US

V. Phone/Fax

Practice location:
  • Phone: 619-933-3771
  • Fax:
Mailing address:
  • Phone: 619-933-3771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 4099
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: