Healthcare Provider Details

I. General information

NPI: 1932765203
Provider Name (Legal Business Name): MYA R JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W BELTLINE HWY STE 301
MADISON WI
53713-4228
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 262-789-1191
  • Fax:
Mailing address:
  • Phone: 262-999-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number126747
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11515-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: