Healthcare Provider Details

I. General information

NPI: 1295841658
Provider Name (Legal Business Name): GWENDOLYN O JOHNSON LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 N CHARLES ST
BALTIMORE MD
21218
US

IV. Provider business mailing address

2225 N CHARLES ST
BALTIMORE MD
21218
US

V. Phone/Fax

Practice location:
  • Phone: 410-366-4360
  • Fax: 410-243-7948
Mailing address:
  • Phone: 410-366-4360
  • Fax: 410-243-7948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number04394
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: