Healthcare Provider Details

I. General information

NPI: 1396894259
Provider Name (Legal Business Name): CAROLYN M MARTIN-JOHNSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 SIXTH ST INNOVATIVE COUNSELING, INC
GREEN BAY WI
54304-2252
US

IV. Provider business mailing address

1499 SIXTH ST INNOVATIVE COUNSELING, INC
GREEN BAY WI
54304-2252
US

V. Phone/Fax

Practice location:
  • Phone: 920-497-6161
  • Fax: 920-498-0476
Mailing address:
  • Phone: 920-497-6161
  • Fax: 920-498-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14160
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4155-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: