=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336264829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILD, MARRIAGE & FAMILY THERAPY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 06/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6939 MARINER DR SUITE C
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53406-3938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-886-8702
-----------------------------------------------------
Fax | 262-886-8714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6939 MARINER DR SUITE C
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53406-3938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-886-8702
-----------------------------------------------------
Fax | 262-886-8714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. SHARON L JOHNSON VISOR
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 262-886-8702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1035-132
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 947-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 521-126
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1012-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2254-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2031-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 369-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------