Healthcare Provider Details

I. General information

NPI: 1487203477
Provider Name (Legal Business Name): LARRY DARNELL JOHNSON LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4039 TALL PINES CT
MARION IA
52302
US

IV. Provider business mailing address

4039 TALL PINES CT
MARION IA
52302
US

V. Phone/Fax

Practice location:
  • Phone: 319-389-5833
  • Fax: 319-368-3358
Mailing address:
  • Phone: 319-389-5833
  • Fax: 319-368-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096283
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: