Healthcare Provider Details

I. General information

NPI: 1568767317
Provider Name (Legal Business Name): CLYDE JOHNSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 N 14TH ST
NEW CASTLE IN
47362-4311
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-1928
  • Fax: 765-741-0335
Mailing address:
  • Phone: 765-288-1928
  • Fax: 765-741-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006487A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: