Healthcare Provider Details

I. General information

NPI: 1982938833
Provider Name (Legal Business Name): MARJORIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 ONTARIO ST
OAK PARK IL
60302-1913
US

IV. Provider business mailing address

942 ONTARIO ST
OAK PARK IL
60302-1913
US

V. Phone/Fax

Practice location:
  • Phone: 708-383-3441
  • Fax: 708-383-3441
Mailing address:
  • Phone: 708-383-3441
  • Fax: 708-383-3441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149007642
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: