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General NPI Number Information
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NPI Number | 1598848921
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Entity Type | Individual
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Provider Name | MARY KAY JOHNSON LCSW CSW PIP QMNP
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Gender | Female
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Dates
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Enumeration Date | 10/21/2006
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Last Update Date | 05/06/2022
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Provider Practice Location Address
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Address Line | 1103 JENSON AVE SE
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City | WATERTOWN
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State | SD
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Zip | 57201-5259
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Country | US
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Telephone | 605-878-1234
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Fax | 605-878-2211
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Provider Business Mailing Address
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Address Line | 1103 JENSON AVE SE
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City | WATERTOWN
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State | SD
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Zip | 57201-5259
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Country | US
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Telephone | 605-878-1234
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Fax | 605-878-2211
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LCSW 1557
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | CSW PIP 1991
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License Number State | SD
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