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General NPI Number Information
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NPI Number | 1679202758
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Entity Type | Individual
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Provider Name | MARY ELIZABETH JOHNSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/06/2022
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Last Update Date | 01/21/2025
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Provider Practice Location Address
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Address Line | 1329 AMMON PARK DR
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City | AMMON
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State | ID
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Zip | 83406-4591
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Country | US
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Telephone | 208-403-0135
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Fax |
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Provider Business Mailing Address
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Address Line | 30131 BULVERDE LN UNIT 371
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City | BULVERDE
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State | TX
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Zip | 78163-8821
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Country | US
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Telephone | 602-300-7302
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Fax |
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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 | 65860
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License Number State | TX
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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 | 8911068
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License Number State | ID
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