Healthcare Provider Details

I. General information

NPI: 1013871219
Provider Name (Legal Business Name): CHARLIE-MAE JOHNSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PILGRIM PARK RD
WATERBURY VT
05676-1735
US

IV. Provider business mailing address

324 DALTON RD
DALTON NH
03598-5723
US

V. Phone/Fax

Practice location:
  • Phone: 802-474-1878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0136799PROV
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: