Healthcare Provider Details

I. General information

NPI: 1154912905
Provider Name (Legal Business Name): CAITLIN IRENE JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOSPITAL DR
COLUMBIA MO
65201-5275
US

IV. Provider business mailing address

116 TRACY DR
COLUMBIA MO
65203-2208
US

V. Phone/Fax

Practice location:
  • Phone: 573-814-6000
  • Fax:
Mailing address:
  • Phone: 573-694-8584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2021003121
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: