Healthcare Provider Details

I. General information

NPI: 1619119062
Provider Name (Legal Business Name): HEIDI MAREE JOHNSON LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 EASTERN AVE
BALTIMORE MD
21224-4208
US

IV. Provider business mailing address

6541 SPECKER AVE
FORT CARSON CO
80913-4263
US

V. Phone/Fax

Practice location:
  • Phone: 410-558-4900
  • Fax: 410-732-7000
Mailing address:
  • Phone: 719-526-7876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13826
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: