Healthcare Provider Details

I. General information

NPI: 1205342664
Provider Name (Legal Business Name): SHEILA RENEE JOHNSON CSW-PIP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 W MAIN ST
RAPID CITY SD
57702-8170
US

IV. Provider business mailing address

1330 JOLLY LN
RAPID CITY SD
57703-4763
US

V. Phone/Fax

Practice location:
  • Phone: 605-737-6081
  • Fax: 605-737-6015
Mailing address:
  • Phone: 605-343-2811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3492
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3492
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: