Healthcare Provider Details

I. General information

NPI: 1518094184
Provider Name (Legal Business Name): BEVERLY ELAINE JOHNSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 64 OLD HIGH SCHOOL ROAD
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 7454 APT #180
NEWCOMB NM
87455-7454
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-5163
  • Fax: 505-368-5502
Mailing address:
  • Phone: 505-696-3348
  • Fax: 505-696-3265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-06201
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: