=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487822995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL PETTY JOHNSON MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2008
-----------------------------------------------------
Last Update Date | 02/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5959 WEST LOOP S SUITE 515
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77401-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-8882
-----------------------------------------------------
Fax | 713-977-2319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5959 WEST LOOP S SUITE 515
-----------------------------------------------------
City | BELLAIRE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77401-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-660-8882
-----------------------------------------------------
Fax | 713-977-2319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0440
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------