Healthcare Provider Details

I. General information

NPI: 1235656554
Provider Name (Legal Business Name): CORLISS J. JOHNSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 EASTLAND RD
BEREA OH
44017-1217
US

IV. Provider business mailing address

2148 EAGLE PASS STE H
WOOSTER OH
44691-5357
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-2916
  • Fax:
Mailing address:
  • Phone: 330-345-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS1501115
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS150115
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: