Healthcare Provider Details

I. General information

NPI: 1083768345
Provider Name (Legal Business Name): CYNTHIA LYNN JOHNSON LCSW LICENESED CLINI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CYNTHIA LYNN SMITH

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 ASH ST
ADAMSVILLE TN
38310-4961
US

IV. Provider business mailing address

PO BOX 61
ADAMSVILLE TN
38310-0061
US

V. Phone/Fax

Practice location:
  • Phone: 731-315-1213
  • Fax: 731-315-1213
Mailing address:
  • Phone: 731-315-1213
  • Fax: 731-315-1213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW0000004454
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: